Message from the
Commissioners
in April 2020,
in the first weeks of the COviD-19 pandemic, the most lethal mass shooting in
Canadian civilian history unfolded over 13 terrible hours in Nova Scotia. A perpetrator shot and killed 22 people,
one of whom was expecting a child. Many more
people were harmed and affected,
across Canada, the United States,
and beyond.
On behalf of all Canadians, the
governments of Canada and Nova Scotia estab-
lished the Mass Casualty Commission in October 2020 to determine
what happened, how and why it happened, and to set out lessons
learned as well as
recommendations that could help prevent and respond to similar incidents in the
future. After two and a half years of independent and thorough investigation,
this Report comprehensively fulfills the Commission’s mandate.
Our
recommendations are designed with two objectives in mind: prevention of
violence and ensuring effective critical incident response by police, other
public safety partners, health and victim service providers, and communities. Crucially, we also consider the broader
root causes of violence, how such violence can be prevented, and how we can all
help to improve community safety and well-being.
There were many warning
signs of the perpetrator’s violence
and missed oppor- tunities to intervene in the years before the mass casualty.
There were also gaps
and errors in the critical
incident response to the mass casualty as it unfolded
on April 18 and 19, 2020. Additionally, there were failures in the
communications with the public during
and in the aftermath of the mass casualty. These issues can be addressed, and responses, including public
alerting, can be improved.
The future of the RCMP and of provincial policing requires focused
re-evaluation. We need to rethink the role of the police in a wider ecosystem of public safety. Sig- nificant
changes are needed to address various community safety and well-being
TURNING THE TIDE TOGETHER • Executive Summary
and Recommendations
needs of the
21st century. The existing culture of policing must change. issues around
interoperability between emergency responders and other community safety
partners, for example, require improvement. Everyday policing practices, policies,
supervision, information-sharing, learning, transparency, and accountabil- ity require
attention across the board, beginning
with an overhaul of police edu-
cation in Canada. As our Report details,
there are significant steps that the RCMP,
municipal police, and other public safety partners can take to improve
prevention, timely intervention, and, when needed, critical incident response.
Most important, the RCMP must finally undergo the fundamental change called for
in so many pre- vious reports. This transformation must begin with recruiting
and education, and from there extend
to all aspects of the RCMP’s work.
in addition to rethinking policing, it is critically important
that we address the root causes of violence. We must acknowledge and address social factors like poverty
and inequality because it is clear that the social determinants of
health are also the social determinants of community safety.
We need to accept that those who perpetrate mass casualties often have
unaddressed histories of gender-based, inti- mate partner, or family violence –
which means that tackling those forms of vio- lence must be an urgent priority.
valuing all members of our communities, from childhood onward, will contribute to making our communities safer for everyone.
We must invest in a public safety system that is about more than police ser-
vices, where multiple partners work together every
day with substantial commu- nity engagement. Community safety planning needs to take
social development, prevention, early intervention, and critical incident response into account. This approach means that public policy and
funding should put crime prevention on an equal footing with enforcement. The police should
be understood as a part of the
community safety net. Their important responsibilities to ensure public safety
are shared with community members as well as with other organizations and
institu- tions. This collaboration will enable each partner in community safety
to focus on the
aspects of public safety that best suit their knowledge
and expertise.
Across our
country, we all have work to do. The Public inquiry that led to this Report is
proof we can work together. This Report, like all the Commission’s work, is the
result of the contributions of many people, including the families, Participants and their counsel,
emergency responders, witnesses, participants in roundtables and other discussions, community organizations, the media,
service providers, the public, and the Commission team. Once again, we thank everyone for contributing
to this important work. in addition, we acknowledge with gratitude that with our
Message from the Commissioners
work in Nova
Scotia, we were guests in Mi’kma’ki, the ancestral and unceded terri- tory of
the Mi’kmaq.
Turning the tide on the underlying causes of violence
in our communities will take
courage, commitment, and collaboration. it will take courage to admit that we
face a set of interconnected and complex challenges and that we must resist
defaulting to the simplistic answers and impulsive responses that have failed
us all too often in the past. As a country, we need to commit to persisting
month after month, year after year, making steady improvements and sustained
efforts to shift entrenched values, fix broken systems,
and make violence
prevention our guid- ing star. it will take
collaboration from all Canadians – including leaders, policy- makers, emergency
responders, service providers, public institutions, community groups, and
members of the public – to turn the tide. By working together, you helped us to
develop meaningful, practical, and sustainable recommendations for the future.
Now we call on you to help implement these recommendations, which will contribute to ensuring safer communities for everyone. We all have work to do. it is time to act.
Sincerely,
The Mass Casualty Commission Hon. J. Michael MacDonald,
Chair
Leanne J. Fitch
(Ret. Police Chief,
M.O.M.) Dr. Kim Stanton
PART B: THE MASS CASUALTY
From Saturday
evening, April 18, to Sunday morning, April 19, 2020, a perpetrator shot and killed 22 residents of Nova Scotia,
one of whom was expecting
a child. He also wounded three
more people before
being killed by RCMP officers
in the ensuing
manhunt. His 13-hour rampage extended through several communities in the central
part of Nova Scotia. in addition to these gun-related deaths and injuries, many other types of harm resulted
from the perpetrator’s actions.
Please see the pictures
and memories that the families
of those whose
lives were taken chose to
share with the Commission, in Part A, Commemoration.
The mass
casualty affected a broad range of people, most significantly the families of
those whose lives were taken, as well as other individuals, groups, and
organiza- tions, including:
• witnesses who were there,
saw what was happening, and were in harm’s way;
• first responders and service people,
including police, emergency health service professionals, firefighters, and others providing front-line services;
• people living in the affected communities whose friends and
neighbours were taken and whose sense of community safety was severely
affected; and
• many people in Nova Scotia, Canada, the United States, and beyond.
Rural
communities much like those affected by the mass casualty are dotted across our country. The many lessons
learned in this inquiry must be understood, actions taken, and recommendations
applied. Doing so will better protect the peo- ple and places we love, from sprawling rural
spaces to First
Nations communities to urban
centres from coast to coast to coast.
volume 2 of the Final Report
provides a detailed
account of what happened on April 18 and 19, 2020. The next three volumes – volume 3, violence; volume 4, Com- munity;
and volume 5, Policing – supply further facts and analysis of the causes, context,
and circumstances of the mass casualty. This overview does not substitute for
the information and analysis provided in these volumes. Rather, its purpose is to supply a chronology
of the mass casualty, focusing on the perpetrator’s actions
and on key aspects of the police response, in order to provide the context for the
overall work of the Commission as described below.
Although this
overview focuses on the perpetrator’s actions and on the formal public safety system response
to the mass casualty, community
members played a crucial role
at every stage. Most poignantly, they included Jamie Blair, Lisa McCully, Tom
Bagley, Joseph (Joey) Webber, Andrew MacDonald, and others who died or were injured while responding
directly to the chaos caused by the perpetrator. They also included, for
example, community members who called 911 to offer information about the
perpetrator, his disguise, and his whereabouts, and those who shared
information directly with RCMP members as they were engaged in the critical incident
response. These community
members showed courage and selflessness in their efforts
to protect others. in Chapter 2 of volume 2, What Happened, we find that
community members played an indispensable role in the response and that this
role was not adequately acknowledged by the RCMP.
For a complete understanding of
the mass casualty, we urge you to read the Final Report in its entirety.


The perpetrator
was a white, wealthy male in his early 50s. He was a denturist, with clinics in
Dartmouth and Halifax. He lived part of the time in Dartmouth and part of the
time in Portapique, where he owned two properties: a well-appointed cottage and
a nearby “warehouse” – a large structure that also contained a bar and guest
accommodation. He stored many of his possessions at the warehouse.
The perpetrator was raised in a violent
home and became a violent
man. A cur- sory overview of his life reveals the long history of
violence in his family of origin. He witnessed family violence, including
intimate partner violence, at a young age. He was abused by his father, who was
also violent to others outside the family. We
learned that violence
in the perpetrator’s family extended
back several genera- tions. There is evidence that
intergenerational violence in his family affected many of the perpetrator’s
relatives.
As an adult, the perpetrator
developed an alcohol use disorder and was known to become violent
when he drank to excess. Beginning as a youth and continuing as an adult,
the perpetrator engaged
in violent and intimidating behaviour – a pattern that extended to intimate
partners, to friends, neighbours, and business associates, and to patients and community members,
particularly those who were marginal- ized. Many people experienced
violence and intimidation in their interactions with him, and many others
were aware of it.
On several
occasions, individuals reported him to the police and other authorities, but
only one report resulted in a criminal charge – for assaulting a teenage boy.
in 2002, he pled guilty to this charge and was granted a conditional discharge
– one of the conditions being that he attend anger management assessment
programs
and counselling as directed by his probation officer. The perpetrator also uttered threats to commit violence
using firearms against
his parents in 2010 and against
the police in 2011. Both these threats
were reported to the police.
Lisa Banfield was the perpetrator’s long-term
common law spouse,
and she worked for him in his denturist clinic. Over 19 years, their
relationship was marked by his violence, coercion,
and controlling behaviour
toward her. The perpetrator
was physically violent with her and threatened her with a firearm on more than
one occasion. He also inflicted other
forms of abuse,
including verbal and emotional
abuse and financial control, and was controlling and possessive in his behaviour toward her. Some individuals
attempted to intervene in this pattern of violent, abu- sive, and coercive behaviours. Others stood by and watched
him assault her. He
frequently threatened to harm her or her family if she left him. On at least
one occasion, in 2013, the perpetrator’s violence toward Ms. Banfield was reported to the
police.
The perpetrator owned at least five firearms
at the time of the mass casualty.
He did not hold a possession and acquisition licence,
so he possessed them illegally. He smuggled three of these firearms
into Canada from the United
States. He also had significant amounts of
ammunition and a hand grenade. He had shown some of these firearms to several
individuals, including his family, his neighbours, and members of Ms. Banfield’s family. On three occasions, someone
reported his pos- session of firearms to the police.
At the time of
the mass casualty, the perpetrator owned four decommissioned police vehicles.
He purchased them through GCSurplus, the Government of Canada’s online auction
site. He then sought out various items to transform one of the decommissioned
vehicles into a strikingly accurate replica of an RCMP cruiser. He told many people
about the replica
RCMP cruiser, and several had seen it in real life or in photographs. The
perpetrator possessed several items of RCMP uniform, including a full
traditional dress uniform and a general duty uniform shirt, dark blue pants
with a yellow stripe, and Stetson hat. He also had various items of police kit,
including handcuffs. He acquired these items primarily through friends and
family.
The perpetrator
was deeply affected by the COviD-19 pandemic. in the weeks before the mass
casualty, his denture clinics had been required to close as part of the public health
measures that were then in place. He and Ms. Banfield moved from their main
residence in Dartmouth to the cottage in Portapique. in the period after the clinic shut down, Ms. Banfield reported
that he became
“agitated and par- anoid” and was not sleeping or eating much.
He stockpiled large
quantities of food,
gas, and ammunition and withdrew $475,000 from the Canadian imperial Bank of Commerce (CiBC). His behaviour became
erratic and was increasingly concerning to Ms. Banfield.
The mass
casualty began before 10:00 pm on April 18, 2020, with the perpetrator’s
violent assault of Lisa Banfield in the Portapique cottage. Physical evidence
found by RCMP investigators corroborates her account.
The perpetrator inflicted serious injuries
on Ms. Banfield, including fractures to her ribs and
lumbar spine, before setting the cottage on fire and forcing her to accom- pany him to his nearby warehouse. When she tried
to resist him, he took her shoes and threw them into the woods. She attempted to run away, but he used his flash-
light to find her and grabbed her again.
Once they were inside
the warehouse, the perpetrator handcuffed Ms. Banfield’s left hand. He demanded her other hand,
but she dropped
to the floor and pleaded
with him. When she refused to get up, he fired
his handgun into the ground
on either side of her. He forced her into the back seat of his replica RCMP cruiser and shut the door. The back and front seats of the car were separated by a steel and Plexiglas barrier with a sliding
window. As is typical of police vehicles, the rear doors
could not be opened
from the inside.
Ms. Banfield
was trapped inside
the back of the car while the perpetrator loaded firearms into the front seat and
moved around the warehouse. She was able to pull the single handcuff
off her wrist, causing injuries
later documented in medical
records, open the window in the barrier, and slide through it into the front
seat. From there, she opened the driver’s door and fled from the warehouse.
Ms. Banfield hid
overnight in the woods in Portapique, where she heard and observed
things that made her believe the perpetrator was still in the area looking
for her. The perpetrator set fire to his warehouse. Both the cottage
and the ware- house became fully
engulfed in flames
that were visible
in the surrounding areas.
Within minutes
of these events, at approximately 10:00 pm, the perpetrator arrived at the home
of his neighbours Greg and Jamie Blair on Orchard Beach Drive. This couple ran
a business providing sales, service, and installation of natural gas and
propane units in the Truro area. They loved fishing, cooking, the outdoors, and time
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Perpetrator’s Movements in Portapique, April 18, 2020
|
1 |
Before 10:00 pm |
Perpetrator assaults Lisa Banfield at
the cottage |
|
2 |
Before 10:00 pm |
Perpetrator sets fire
to warehouse |
|
3 |
10:00 pm |
Homicides of Greg
and Jamie Blair |
|
4 |
10:08 pm |
Homicide of Lisa McCully |
|
5 or 6 |
Between 10:08 and 10:20 pm |
Homicides of Joy and Peter
Bond |
|
5 or 6 |
Between 10:08 and 10:20 pm |
Homicides of Jolene
Oliver, Aaron Tuck, and Emily Tuck |
|
7 |
Between 10:20
and 10:25 pm |
Homicides of Dawn and Frank
Gulenchyn |
|
8 |
10:26 pm |
Perpetrator encounters Andrew
and Kate MacDonald |
|
9 |
Approximately 10:27
pm |
Perpetrator at intersection of
Portapique Beach Rd. and Orchard Beach Dr. |
|
10 |
10:28–10:38 pm |
Homicides of Joanne Thomas and John Zahl |
|
11 |
10:38–10:39 pm |
Perpetrator travels through
trail on lot 287 |
|
12 |
10:40 pm |
Homicide of Corrie
Ellison |
|
13 |
Approximately 10:41
pm |
Perpetrator proceeds to blueberry field road via Cobequid Crt. |
|
14 |
Approximately 10:41–10:45 pm |
Perpetrator exits onto
Brown Loop |
Map Data | Google,
©2023 CNES / Airbus
with their family. The perpetrator shot and killed Mr. Blair on the deck of his home. At 10:01 pm, Ms. Blair called 911
and said that her neighbour had shot her husband. She identified the perpetrator by first name and described
the replica RCMP cruiser,
but explained he was not a police officer. Ms. Blair instructed her two children
to hide. While she remained on this phone call and sought to protect her
children, the perpetrator entered the Blair residence, shot the family cat and dog, and then killed Ms. Blair. He pulled
logs from the woodstove and scattered them across the living
room in an apparent attempt
to cause the house to catch fire. He also turned on the
propane stove and piled items on top of it before leaving the residence. There
is no indication he noticed
the hiding children.
Within minutes
of Jamie Blair’s
911 call at 10:01 pm on April
18, police resources and an ambulance were
dispatched to Portapique. The information provided to these first responders by
the RCMP Operational Communications Centre was incomplete: key details such as
the fact that the perpetrator was driving a “fully decked and labelled RCMP”
car but was not a police officer were not conveyed. Four uniformed general duty
members of the RCMP Bible Hill detachment – Acting Cpl. Stuart Beselt, Cst.
victoria (vicki) Colford, Cst. Adam Merchant, and Cst. Aaron Patton – proceeded
to Portapique in separate vehicles from various locations around Bible Hill.
They travelled at high speed using police lights and sirens.
Between 10:05
pm and 10:20 pm on April 18, the perpetrator took the lives of six more people.
His precise movements in that 15-minute period are somewhat
uncer- tain, but the following account
represents the most likely chronology based on all the
evidence obtained by the Commission.
The Blair children continued
to hide until smoke forced them to flee their home.
They ran to the house next door, where Lisa McCully lived with her children.
Ms. McCully was a mother and a teacher at the elementary school in Debert. She
enjoyed the quiet of Portapique and spending time outdoors, biking,
snowshoe- ing, and fishing. She was a neighbour of the perpetrator.
Before the Blair children arrived at
her home, Ms. McCully and one of her two children had noticed the fire across the road at the perpetrator’s warehouse and heard
the sounds of explosions.
Ms. McCully left her home at approximately 10:08 pm to respond to these devel- opments. The perpetrator shot and killed her soon after, most likely while driving
south along Orchard Beach Drive after leaving
the Blair home. The Blair children
arrived at the McCully residence at approximately 10:16 pm, and the McCully
chil- dren brought them inside the house. The four Blair and McCully
children called
911 and remained on the phone
with the call-taker until they were evacuated from Portapique more than two hours
later.
After the
perpetrator killed Ms. McCully, he travelled south in his replica RCMP cruiser to Cobequid Court to the residence of Joy and Peter Bond and the separate
residence of Jolene Oliver, Aaron
Tuck, and Emily
Tuck. After raising
their two sons near Chester, Nova Scotia,
Joy and Peter Bond moved in 2007 to their retirement
home in Portapique. As the parents of 17-year-old Emily, Mr. Tuck and Ms.
Oliver moved their family from Alberta to Nova Scotia in 2014. Mr. Tuck was good with his hands
and liked restoring cars, while Ms. Oliver loved nature and was known for her
infectious laugh. Emily was creative and played the fiddle. They enjoyed
spending time together as a family at their house in Portapique. The Bonds and the Oliver /
Tucks knew the perpetrator as a neighbour.
The perpetrator shot these five residents inside
their respective homes.
He did not set fire to either residence. No information is available
to determine the order in which he went to the residences on Cobequid Court. We
know that Emily Tuck was alive at 10:03 pm, the time she sent her last text message
to a friend. Despite receiving
calls from concerned family and community members beginning on the morning of April 19, the RCMP did not find these victims until the late afternoon of April
19.
After killing
the Bonds and the Oliver / Tucks, the perpetrator retraced his route, driving
north on Orchard Beach Drive past his warehouse and the McCully and Blair homes. He arrived
at the residence of Dawn and Frank Gulenchyn sometime before 10:25 pm. Before retiring to Nova Scotia from Ontario, the Gulenchyns had carefully
renovated their home in Portapique. The perpetrator shot and killed them and
set their home on fire.
Andrew and Kate MacDonald lived on
Portapique Beach Road. As they were pre- paring for bed, they observed what appeared to be a massive fire.
Concerned, and unsure whether
anyone had reported the fire, they got into their car to investi- gate. On their way, they drove past the Gulenchyn residence
and noticed what they
believed to be an RCMP cruiser in the driveway. At 10:25 pm, after confirming the location of the fire at the perpetrator’s warehouse, Mr. MacDonald called 911. While on the phone, he turned the car around and drove back north on Orchard Beach Drive. They noticed that the kitchen
of the Gulenchyn residence was also on fire.
The perpetrator’s replica RCMP cruiser was still in the Gulenchyns’ driveway, and Mr. MacDonald
initially mistook the perpetrator for a police officer. The replica
RCMP cruiser pulled out of the driveway and drew up alongside the MacDonalds’ vehicle while they remained on the 911 call. The perpetrator fired two shots at them. Mr.
MacDonald was shot in his shoulder, and another bullet grazed his head. He was
able
to drive away, followed by the perpetrator and a second vehicle later identi-
fied as belonging to the Faulkner family. At the intersection, Mr.
MacDonald turned north onto Portapique Beach Road and the Faulkners followed
them. As the MacDonalds approached Highway 2, they encountered the first RCMP members,
who were just arriving at Portapique. The perpetrator turned south down
Por- tapique Beach Road, away from Highway 2 and the responding RCMP members.
Mr. MacDonald knew Acting Cpl. Beselt, the first arriving RCMP member, and they had a brief conversation. Cst. Patton also spoke with the MacDonalds and broad- cast information he learned from them, including
the short form of the perpetra-
tor’s first name, his approximate age and occupation, and the fact he had a car that
looked like a police car.
Within 30 minutes of the first fatality in Portapique on April 18, 2020, the RCMP
had received three 911 calls
about the active
shooter situation. Jamie
Blair, the Blair and McCully children, and Andrew and Kate MacDonald
all identified the perpetra-
tor by first name and provided other identifying characteristics such as that
he was a neighbour and a denturist. These callers each said the perpetrator had
a police car, but was not a real police
officer, or that he had a car that looked
exactly like an RCMP car. They provided identifying
information, including that the car was white and had RCMP decals on it.
important information from these
911 calls was not passed on to responding mem- bers or captured within
the text-based incident
logs produced by call-takers and dispatchers. in particular, the RCMP
discounted the clear information coming from Portapique community members that the perpetrator was driving a fully marked RCMP vehicle. Priority was placed
on determining whether all RCMP vehicles in Nova Scotia were accounted
for, to rule out the possibility that any of these vehi- cles were involved in the critical
incident. This investigative step was reasonable, but it led to a false conclusion that the eyewitness accounts were mistaken.
Based on the information Mr. MacDonald provided
that the perpetrator was an active shooter,
Acting Cpl. Beselt decided that he and Cst. Merchant should begin an immediate
Action Rapid Deployment (iARD) response. The RCMP Oper- ational Manual defines iARD as “[t]he swift and
immediate deployment of law enforcement resources to an on-going, life threatening situation, where delayed
deployment could otherwise result in grievous
bodily harm and/or death to inno-
cent persons.”
Acting Cpl. Beselt and Cst. Merchant
proceeded south on foot along Portapique
Beach Road. They were soon joined by Cst. Patton, also on foot. We refer to these three
RCMP members as the iARD responders.
The other
responding member from the Bible Hill detachment, Cst. Colford, remained near
the intersection of Portapique Beach Road and Highway 2 to prevent the
perpetrator from escaping by that route. She also spoke to the MacDonalds as they awaited
medical attention. Starting
at 10:43 pm, additional
RCMP members began to arrive at Portapique. These members attempted to establish
a perimeter to prevent the perpetrator from escaping the area.
RCMP policy requires
that a scene commander be designated at a critical
inci- dent that entails
an iARD response, but no one was appointed to fill that role. The absence of a trained scene commander
had a significant adverse impact on the RCMP’s critical incident response in
Portapique.
RCMP policy did not clearly assign supervisory
roles and responsibilities for the period
before a critical incident commander assumes command of the critical inci- dent response.
Uncertainty about these roles and responsibilities was evident from an early stage within the RCMP’s response in Portapique.
We find in volume 2, What Happened, that the RCMP member who held initial
com- mand of the critical incident response in Portapique was S/Sgt.
Brian Rehill. On the night of April 18, 2020, S/Sgt. Rehill was the risk
manager in the RCMP Operational Communications
Centre, which was then located in Truro, Nova Scotia. Risk man- agers are non-commissioned officers with
significant operational experience who are available to general duty members to
provide supervision and guidance. They work closely with 911 call-takers and
dispatchers (civilian employees of the RCMP who
also operate within the Operational Communications Centre). Risk managers can
monitor incidents by reading the electronic (text-based) incident activity log produced by call-takers and dispatchers
and by listening to police radio. RM Rehill (as we call him during his hours on
duty on April 18 and 19) began monitoring the
Portapique incident after Ms. Blair’s 911 call.
RM Rehill was not a trained
critical incident commander. At 10:35 pm, when the scale of the incident was becoming
apparent to the first-responding members in Portapique, RM Rehill notified the
acting district operations officer, Acting insp. Steven (Steve) Halliday,
of the incident. By 10:38 pm, Acting insp. Halliday,
S/Sgt. Allan
(Addie) MacCallum, and S/Sgt. Allan (Al) Carroll had been contacted. in April
2020, these three non-commissioned members were all key members of the
supervisory group in the Northeast Nova District, which comprises most of
northern Nova Scotia. At 10:42 pm, Acting insp. Halliday phoned an on-call
crit- ical incident commander, S/Sgt. Jeffrey (Jeff) West, who was based in the
Hali- fax area. Supt. Darren Campbell, the support services officer, quickly
approved the deployment of the critical incident commander and specialized
resources such as the Emergency Response
Team (ERT) and Police Dog Service.
RM Rehill
remained in command of the RCMP’s critical incident response for more than
three hours, while also performing his duties as risk manager. After S/Sgt.
West was called out, he arranged for a trained scribe, Sgt. Robert (Rob) Lewis,
to record his decisions and actions and obtained equipment from RCMP H Division
headquarters in Dartmouth. S/Sgt. West and Sgt. Lewis travelled from Dartmouth
to Great village (approximately 10 kilometres east of Portapique), where S/Sgt.
West established a critical incident command post in the Great vil- lage fire
hall.
Sgt. Andrew (Andy) O’Brien was the operations
officer for Bible Hill detachment. He was off duty on April 18. After Acting
Cpl. Beselt called
to alert him to the seri-
ous incident in Portapique, Sgt. O’Brien phoned
his supervisor, S/Sgt.
Carroll, and informed him he
had consumed alcohol and should not attend the scene. His con- sumption of
alcohol was in no way improper – he was off duty and not on call. However, from
approximately 10:30 pm on, Sgt. O’Brien participated in the criti- cal incident
response in a supervisory capacity, without attending the scene. The RCMP
Code of Conduct rule about member consumption of alcohol is poorly
framed. We conclude in volume 5, Policing, that the only appropriate standard
for RCMP members is that they should have no alcohol
or recreational drugs in their system when on duty. A member who
has consumed alcohol or recreational drugs should not report for duty or
self-deploy.
The RCMP members who responded to the mass casualty had limited knowledge of the Portapique
community and geography. it was dark, with few sources of arti- ficial light,
and there was smoke in the air. The RCMP members on scene could
hear explosions and sounds like gunshots. Acting Cpl. Beselt used the
navigation fea- tures of his personal cellphone to orient himself
and the other
iARD responders as they
moved through the Portapique subdivision. RCMP-issued cellphones had no
data, and therefore no navigation capacity of this kind. The RCMP did not seek
out local knowledge about the geography of the area or about alternative routes out of
the community.
After the perpetrator turned south on Portapique Beach Road, he travelled past his cottage to the residence of
Joanne Thomas and John Zahl, at 293 Portapique Beach Road. Retirees who had
come to Portapique from New Mexico in 2017, the couple quickly became involved
in local community
and charity work. They lived in
a home immediately next to property owned by the perpetrator. in volume 2, we conclude that the
perpetrator shot Ms. Thomas and Mr. Zahl before setting their home on fire. Ms.
Thomas and Mr. Zahl were killed sometime between 10:28 pm and 10:39 pm.
After
leaving the Thomas / Zahl residence, the perpetrator drove his replica RCMP cruiser on a trail through the woods on his property from
the southern portion of Portapique Beach Road to his warehouse at 136 Orchard
Beach Drive.
Corrie Ellison and Clinton Ellison were
visiting their father, Richard Ellison, in Por- tapique on the evening of April 18. Corrie Ellison grew up in
Truro and had many friends in the area. The brothers heard what sounded
like a gunshot and stepped outside, from where they could see flames rising
above the treeline. Shortly after,
Corrie Ellison said he would go to investigate the source of the fire. At 10:36 pm, he phoned his father to say the fire was at 136 Orchard Beach
Drive. He used his cell- phone to take photographs of the fire.
At approximately 10:40 pm, the perpetrator encountered Corrie Ellison just south
of the driveway to the warehouse and fatally shot him. The shots that killed
Mr. Ellison were heard and reported by the Blair and McCully children (who
remained on their call with 911) and the iARD responders.
Witness accounts provided different
and in some aspects conflicting informa- tion about the perpetrator’s exit from Portapique. We conclude on the basis of all the
evidence that the perpetrator left Portapique immediately after killing Corrie Ellison. From that point, he travelled
south, to the intersection of Cobequid Court, and turned left to proceed east
along Cobequid Court to a dirt track that was known in the community as the
blueberry field road – an unmarked, unofficial road that runs alongside a
blueberry field and connects Cobequid Court to Brown Loop and ultimately to
Highway 2. Using this route, before 10:45 pm, the perpetrator accessed Highway
2 and drove east toward Great village. His replica RCMP cruiser was captured
on a video surveillance camera
in Great village
at 10:51 pm.
RM Rehill
began giving directions to secure the perimeter at 10:44 pm on April
18, 2020. At this time, he was overtasked. As the sole supervisor on
duty, without a scene commander on site in Portapique, he was monitoring the iARD responders,
establishing
containment, monitoring information coming into the Operational Communications
Centre via 911 calls, and seeking to secure additional resources such as air
support.
At 10:44 pm, RM
Rehill instructed Cst. Christopher (Chris) Grund, who was driving from Millbrook,
to seal off Highway 2 at Hillview Lane, east of Portapique. However,
at about the same time,
Cst. Jordan Carroll
and Cst. Jeff Campbell were also radio- ing that they were approaching
Portapique from the west, and there was evidently confusion about to whom of
these responding members RM Rehill was directing his instruction.
At 10:48 pm, Cst. Colford broadcast
by police radio the information, provided by Ms. MacDonald, that there might be an alternative route out of Portapique. How- ever, this broadcast was not heard by members
then travelling toward
the scene, RCMP dispatch,
or supervisors who had been engaged by that point.
No containment point was established on Highway 2 east of Portapique until 12:01 am on April 19.
Back in Portapique, after walking
south down Portapique Beach Road, the iARD responders went through the woods
from Portapique Beach Road to 136 Orchard Beach Drive. The warehouse structure
was completely ablaze, emitting intense heat
and periodic explosions.
The iARD responders exited the warehouse property onto Orchard Beach Drive. At 10:49:18 pm, they broadcast the discovery of a
deceased male, subsequently iden- tified as Corrie Ellison. They then made their way across the street to the McCully residence, where they located the
four McCully and Blair children, who were in the home by themselves
and on the phone with 911.
The iARD responders advised the
children to shelter together in the basement, and then they left the home. They remained
outside for a short time to protect the chil-
dren but, consistent
with their training, made the difficult decision to leave them in order to move toward the sounds of ongoing
gunshots and explosions. They were hoping by this means to find and contain
the perpetrator. in the ensuing
hour, the iARD responders periodically returned to check on the children.
Having not heard
anything from Corrie Ellison after his call at 10:36 pm, Richard and Clinton
Ellison grew worried. Both men left the residence: Richard Ellison walked to the end of the driveway
before returning inside, and Clinton Ellison con- tinued north on Orchard
Beach Drive. He illuminated his path with a flashlight.
Clinton Ellison approached the
perpetrator’s warehouse at approximately 10:55
pm. As he did so, he noticed something lying on the ground on the left
side of the road. He shone his flashlight to the area and realized it was the
body of his brother, Corrie. When he saw another flashlight shining in his
direction, he shut off his flash- light and hid in the woods, believing the
person holding the flashlight to be the one who had killed his brother.
At 10:55 pm,
the iARD responders observed light from a flashlight south of them on Orchard
Beach Drive. They suspected this person – later determined to be Clinton
Ellison – to be the perpetrator. The members took up defensive positions on the
lawn of the McCully residence. Mr. Ellison turned off his flashlight and fled
into the woods. The iARD responders began to follow, but, having lost sight of
him and concerned about the possibility of ambush in the woods, ended their
pursuit.
At this time, the police radio became congested: RCMP members on Highway 2 were working to establish a perimeter,
and Cst. Jordan Carroll identified a suspi- cious vehicle in Five Houses – a community
to the west of Portapique on the other side of the Portapique River. RCMP supervisors and responding members
failed to observe radio
protocols – for example, they did not keep non-urgent radio trans-
missions to a minimum at the time when the iARD responders believed they had engaged
the suspect or answer questions asked by the iARD responders, and mul- tiple supervisors intervened to provide
direction at this time. This failure to observe
radio protocols contributed to confusion in the overall response and to
uncertainty about who had overall command of the critical incident response.
Sometime between
10:55 pm and 10:59 pm, Clinton Ellison
was able to contact
his father by phone and tell him that Corrie had been shot. At 10:59 pm, right
after ending the call with his surviving son, Richard Ellison phoned 911. He
reported that fire and explosions were occurring on Orchard Beach Drive and
that his older son (Clinton) had just contacted him to say that his younger
son, Corrie, had been shot. He said that Clinton’s phone had gone dead.
At 10:59:33
pm, the iARD responders broadcast
that they had located the body
of a female victim – later identified as Lisa McCully – beside the front fence
of her residence. They remained near the McCully home for some time to protect
the chil- dren inside. At approximately 11:15 pm, because they had no further
indication of the perpetrator’s likely
location, the iARD responders stopped
actively searching for him.
At 11:10 pm, Operational
Communications Centre dispatch supervisor Ms. Jennifer (Jen) MacCallum
called the risk manager of J Division
(New Brunswick), S/Sgt. Martin
Saulnier, to request
support from the RCMP Atlantic
Region Air Ser- vices. RM Saulnier indicated he
would inquire about availability and call back. Less than 10 minutes later,
RCMP Air Services advised that the helicopter in New Bruns- wick was “Off Duty Sick”
– that is, dismantled for scheduled maintenance. Efforts to secure alternative air support began at this time
and continued overnight and in the early morning of April 19.
Also at 11:10 pm on April 18, the perpetrator’s replica
RCMP cruiser was captured by surveillance footage (later recovered
by the RCMP) entering the Debert Business Park. Some witnesses observed
the perpetrator’s vehicle
as he made his way to
Debert and after he arrived
there.
At 11:16 pm on April 18, Acting
Cpl. Beselt radioed from Portapique to ask whether an emergency broadcast could
be used to tell residents to shelter in their homes. At that time, the RCMP Operational Communications Centre was
using property records to seek to identify and contact Portapique residents – a
laborious and ulti- mately ineffective strategy.
At 11:32
pm on April 18, the RCMP posted
its first tweet
about the mass casualty. This text was prepared by the Strategic Communications Unit using an existing bank of social
media texts and was approved by Sgt. O’Brien. it stated that the RCMP were “responding to a firearms
complaint in the #Portapique area (Portapique Beach Rd, Bay Shore Rd and Five Houses Rd.).”
The public was “asked to avoid the area
and stay in their homes with doors locked at this time.” The phrase “responding to a firearms complaint” in no way
conveyed the threat presented by the perpetrator at that time. This public communication was the only one issued by the RCMP until 8:02 am on April 19, 2020.
Despite the relative lack of
information provided to the public by the RCMP, com- munity members
were taking active steps to share information and to assist one
another both on scene in Portapique and through social media posts. We learned
from community members that messages were being shared as early as 11:00 pm on
April 18. These early messages focused on photos of the fires in Portapique,
but they also shared information about the large police presence in Portapique.
Acting insp.
Halliday, S/Sgt. Carroll, and S/Sgt. MacCallum each began monitoring RCMP radio
communications soon after they were informed of the unfolding inci- dent in
Portapique. S/Sgt. Carroll announced that he was on the air at 11:00 pm. By
11:30 pm, these
three officers had assembled at the RCMP Bible Hill detachment to prepare for the critical incident commander’s
arrival. Acting insp. Halliday
decided to leave RM Rehill in the role of interim incident commander so that he
(Acting insp. Halliday) “could focus
on the big picture.” None of these senior supervisors went to the scene during
the evening of April 18.
Shortly before midnight on April
18, two additional responding RCMP members from the Millbrook detachment – Cst. William
(Bill) Neil and Cst. Chris
Grund – entered Portapique on foot to protect the
four children in the McCully home. At 12:25 am
they decided that Cst. Grund
would use Ms. McCully’s car to drive
the children to the
Great village fire hall, where
a staging (waiting)
area had been established for ambu-
lances and other non-police emergency responders. Meanwhile, Cst. Neil stayed
at the McCully home with the iARD responders. By this time,
members of the Emer-
gency Response Team were en route to Portapique, where they would take over the
active response within the hot zone.
Overnight, the critical incident
command considered whether
to continue to advise
community members to shelter in place or to evacuate
them from Portapique. At 12:27 am, S/Sgt. West, Acting insp. Halliday,
and S/Sgt. Kevin Surette, the second
critical incident commander, who was driving
from Yarmouth and did not arrive
until 5:40 am, decided to wait for the ERT’s arrival in order to set up better
con- tainment and “figure out how to clear [the Portapique] area” safely.
While the
Operational Communications Centre staff, responding members, and the critical
incident command group made sincere efforts to alert residents and safely
evacuate them, the evidence shows that at the time of the mass casualty,
the RCMP had not prepared for
how best to notify community members and execute a large- scale evacuation of
civilians from a hot zone while an active threat was in progress.
By approximately
12:30 am, investigators from the Major Crime Unit had arrived at the Bible Hill
detachment. They met with Acting insp. Halliday, who updated them on the
current situation, and joined the investigation efforts. However, the infor-
mation that the MacDonalds had survived an encounter with the perpetrator and
were available to provide more information to responders had not been recorded
in the RCMP incident log and was not passed along to them. This information did not come to light for several hours.
The critical incident
commander, S/Sgt. West, took command
of the over- all response at 1:19 am on April 19, after arriving at the Great village fire hall and setting
up his command post. Once S/Sgt. West was at the command
post, he requested that
S/Sgt. Carroll, Acting insp. Halliday, and S/Sgt. MacCallum join him. They did so, arriving
between 2:00 am and 2:20 am. Radio and telecommunica- tions and associated
personnel also set up at the command post, together with a crisis negotiator
who tried to contact the perpetrator. RCMP members were gath- ering more information about the
perpetrator and the situation in Portapique while also endeavouring to
understand what had unfolded.
With CiC West now in command
of the incident, RM Rehill continued with risk
manager duties. However, no formal transfer of knowledge and updates from RM
Rehill to CiC West occurred.
For example, CiC West and S/Sgt. Surette
did not review or direct that
an investigator review the 911 recordings to ensure they
had all the information from this source.
The command group
did not review
the inci- dent activity
logs themselves or seek a full briefing
directly from RM Rehill or the
staff at the Operational Communications Centre about what information had been
shared by community members and what was known about
potential witnesses. Nor did
the investigators at the Bible Hill detachment take these steps.
The first H Division
ERT members arrived
on scene in Portapique at 12:34 am on
April 19, approximately one hour and 45 minutes after having been called out.
The slower-moving tactical armoured vehicle arrived after the other ERT
members. At approximately 1:20 am, after the tactical armoured vehicle arrived
at Portapique, it was directed by CiC
West to respond to 911 callers in Five Houses
who reported seeing lights and movement. At 1:31 am, while the ERT
members were responding in Five Houses, Richard
Ellison called 911 to report that he had just spoken to his
son Clinton, who was hiding in the woods near Orchard Beach Drive. A supervisor
from the RCMP Operational Communications Centre called Clinton at 1:42 am. She
spoke to him at length in an attempt to pinpoint his location.
After clearing the call in Five
Houses, H Division ERT members proceeded to Por- tapique in the tactical
armoured vehicle. They entered the community in search of Clinton Ellison just after 2:00 am. The 911 dispatcher
coordinated ERT’s evacuation
of Mr. Ellison. Although ERT had been advised that Mr. Ellison was a
witness and was not a suspect, ERT members handcuffed him and put him in the back of the vehicle. He was dismayed that ERT members did not go up the driveway to locate
his brother’s
body and that his last memory of his dead brother was seeing him while being
driven away, handcuffed, in an armoured police vehicle.
The iARD
responders and Cst. Neil were evacuated from Portapique in the tactical armoured
vehicle at the same time as Mr. Ellison was transported. They drove to the
command post in Great village, where the iARD responders debriefed with Acting
insp. Halliday, S/Sgt. Carroll, and S/Sgt. MacCallum. They explained what they
had seen and done in Portapique, including which houses they had visited and
where they had observed bodies and fires. During the debrief, at approxi- mately
3:00 am, members at the command post learned that Mr. MacDonald was a surviving eyewitness. Even at this stage, it appears that Ms. MacDonald was not similarly
identified. Mr. MacDonald was not interviewed until 5:00 am, two hours after
information about him had been provided directly to the command post. Ms. MacDonald was not interviewed until the following day, April 20.
During the overnight period of April
18/19, the RCMP critical incident
command failed to make a decision on whether to continue advising
Portapique community residents to shelter in place
or to evacuate. Rescue-oriented tasks
such as finding
and evacu- ating community
members or searching for victims who may have been injured but survived were
not initiated until the early morning hours, when the command team discussed checking
the condition of the residents
at the Blair home. Discussions were more focused on securing air support before
initiating an evacuation.
During this overnight period, the critical incident command became concerned about Lisa Banfield’s situation. Steps were taken to
reach Ms. Banfield by phone and to ping her cellphone, in an attempt
to locate her. These efforts
were unsuc- cessful – the
perpetrator had smashed Ms. Banfield’s phone in the initial assault and left it in the burning cottage.
The Halifax Regional Police took some steps to locate her
at the home she shared with the perpetrator in Dartmouth and at the homes of some of her family members in the Halifax area. These efforts were also unsuccess- ful because Ms. Banfield
was still hiding from the perpetrator in the woods.
The command
group’s capacity to coordinate members’
work on the ground in and
around Portapique was hindered by the lack of a scene commander. in addition,
the RCMP was not able to track members’ locations when they were not logged
onto mobile work stations (the computer in RCMP police cruisers) and when they
were outside their vehicles. CiC West did not review containment when he took
command of the critical incident response. The command group did not realize
there was a gap in containment east of Portapique until approximately 5:00 am.
At about that time, Acting insp. Halliday saw a high-quality electronic map of the
Portapique area
and noticed that the blueberry field road might be traversable by car.
Accordingly, at 4:57 am, the command group moved a police vehicle to the corner
of Highway 2 and Brown Loop, to which the blueberry field road connects.
Despite this recognition of a gap in the perimeter, the command group did not
reconsider its belief that the perpetrator was still in Portapique.
By 6:00 am, when there were no new reports from Portapique of fatalities, injuries, or encounters with the perpetrator, personnel at the RCMP command post con-
sidered that he may have died by suicide and that he had taken Lisa Banfield’s
life. As daylight approached, thoughts turned to transitioning from a critical
incident response to a major crime investigation.
in volume 5, Policing,
we explain that critical incident
command decisions should involve the consideration of the
widest and fullest range of explanations for the information available to the
decision-maker, including worst-case scenarios. Con- tingency plans should be developed
based on multiple
potential developments, including the most severe
or serious possible
outcome. These quieter
hours during the early hours
of April 19 – when the critical incident commander was in place at the command post – provided
an opportunity for the RCMP command to take
stock, review, and analyze the information they had received from all sources and to
consider alternative scenarios. This opportunity was lost.
For example, RCMP commanders
believed that the perpetrator was contained in Portapique, and this belief shaped the critical incident
response during the over-
night period. The command group focused on whether the perpetrator was dead or alive, not on where he was located.
Though the fires and sounds of explosions continued into the early hours, as the night wore on the scene in Portapique appeared to quiet down. No one
seemed to take into account the fact that the perpetrator was familiar with the
Portapique area and likely knowledgeable about local roads and trails.
Two factors contributed to the
limited analysis and flawed decision-making that characterized the critical
incident response overnight. The first is that the critical incident command
structure lacked a dedicated information analyst. No one was assigned
the task of reviewing the totality of information and performing an analy- sis of it. The second was a flawed decision-making process,
particularly the failure to consider alternative scenarios
based on the information about the replica RCMP cruiser and mounting reports
about the perpetrator and his firearms.
The RCMP did not provide additional information to the public overnight.
At 5:45 am on
April 19, video surveillance footage captured the perpetrator’s replica RCMP cruiser heading
west on Plains Road from the Debert Business Park toward Highway 4. Less than half an
hour later, the replica cruiser was captured on video surveillance travelling
north on Highway 4 and passing a residence near Folly Lake; at 6:29 am, video surveillance shows the vehicle
travelling north on Hunter
Road, Wentworth.
Shortly after 6:35 am, the perpetrator arrived at 2328 Hunter Road, the home of
Alanna Jenkins and Sean McLeod, both long-time employees of Correctional
Service Canada. Ms. Jenkins worked
at the Nova institution for Women in Truro,
and Mr. McLeod worked at the Springhill institution. Mr. McLeod had met the
per- petrator through a friend in Portapique, and the couple had socialized
with him.
The perpetrator shot one of the family dogs at the residence
and entered the home.
He spent almost three hours in the Jenkins / McLeod home. Evidence suggests he shot the couple before setting
the house on fire. He took Mr. McLeod’s wallet
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Hunter Road and Plains Road, Wentworth
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Map Data | Google, ©2023 CNES / Airbus
from the scene.
The house ultimately burned to the ground, destroying forensic evidence that
may otherwise have assisted with reconstructing the perpetrator’s actions,
including the times of death of Alanna Jenkins and Sean McLeod.
At around 6:20 am, Dave Westlake,
emergency management coordinator of the Colchester Regional
Emergency Management Organization, was contacted by the
Nova Scotia Emergency Management Office and asked to set up a comfort cen- tre
for Portapique evacuees. Mr. Westlake was told there had been a shooting in Portapique and that the residents still in
the area were being evacuated.
At
approximately 6:28 am on April 19, Ms. Banfield left the woods and sought help
from the first house she came to: Leon Joudrey’s residence on Portapique Cres-
cent. Mr. Joudrey let Ms. Banfield inside and, seeing she was shaking and
shivering, gave her his coat and sneakers. He handed her his phone, but she was
so cold she dropped it. He picked it up and called 911.
Five minutes
later, several members of the ERT arrived in the tactical armoured vehicle and
transported Ms. Banfield to the head of Portapique Beach Road. One of the ERT members,
Cst. Benjamin (Ben) MacLeod, carried
out a cursory medical exam and described her as having no visible
serious injuries, although
she was in a “state of terror” and had a distraught, dishevelled appearance. She was having
trouble walking because of lower back pain suffered as a result of the
perpetrator’s assault on her. Emergency Medical
Response Team (EMRT) member Cpl. Duane
ivany assessed Ms. Banfield as moderately hypothermic. He explained that her body was not circulating heat and that this symptom
“indicated to me that she was
outside for an extended period.”
in addition to being a trained EMRT responder,
Cpl. ivany had been a member of the Canadian Ski Patrol for approximately seven
years. He has a great deal of experience with hypothermia from the work he did
in that period.
Ms. Banfield was taken by EMRT
members to an Emergency Health Services ambu- lance staged at the Great village
fire hall. Once the initial medical assessment was complete and before she was
transported to hospital, Ms. Banfield was interviewed for 45 minutes by Cst. Terence
(Terry) Brown and Cst. David (Dave) Melanson in the back of an ambulance. Cst. Brown led the interview, and he described Ms. Banfield as lying on a
stretcher and in visible pain. During the first 15 minutes of this interview, the paramedics assessed
and began treating
her. She provided additional details
to the RCMP members about the perpetrator, and confirmed that he
had a fully marked replica
RCMP cruiser.
At the time when Ms. Banfield was extracted from Portapique, the command post was still making its strategic decisions on
the premise that the perpetrator had likely remained in the Portapique area and was possibly dead. Plans were being
made to transition toward scene investigation, and the question of whether to
evacuate Portapique residents remained under discussion. Around 7:30 am, the command
post received Ms. Banfield’s information about the perpetrator’s replica police cruiser
and, from another
source, a photograph of that vehicle.
Although some evidence suggests that this information prompted members
of the com- mand group to more seriously consider the possibility that the
perpetrator had escaped Portapique, they did not make plans for an active
manhunt.
By 7:55 am, the command group had
confirmed that the perpetrator’s replica RCMP
cruiser was not among the vehicles found
at his properties in Portapique.
Shortly before
8:00 am, Ms. Banfield was transported to the Colchester East Hants Health Centre,
where she was assessed in the emergency
department and then admitted. She was treated in hospital
for five nights and discharged on April 24, 2020.
Most general duty
RCMP members scheduled to work the day shift on April 19 began at around 7:00 am. Some shifts were short-staffed because
members had self-deployed the previous evening – they had joined in the
critical incident response although they were not scheduled to work at that time and without
being directed by a supervisor or a dispatcher to do so.
As members started their
shifts, the briefings they received from their supervisors, the Operational Communications Centre,
and the command post varied and, over- all, were unsystematic and insufficient. Most members picked up as much back- ground information as they could glean from monitoring the radio traffic
and speaking to colleagues. Many RCMP members explained they were
calling other members and listening
to the radio, “trying to gather as much information ’cause
we weren’t getting a whole lot.” Some members relied on information they saw on
social media or information shared
by family. No general instructions were issued by the command post or the risk manager
about what information should be shared with
oncoming members.
A
shift change was also taking place in the RCMP Operational Communications Centre. At 7:00 am on April
19, the risk manager and the Operational Commu- nications Centre were playing an important, but supporting, role in the critical
incident response by capturing incoming information about the mass casualty and
arranging
resources, including extra responding members, for the command post. The
Operational Communications Centre was also responsible for ensuring that other,
unrelated calls were being responded to as necessary.
S/Sgt. Bruce Briers took over the
role of risk manager from S/Sgt. Brian Rehill at approximately 7:00 am. He had already
started gathering information about the ongoing
incident at around 6:00 am, and he asked Halifax Regional Police to share any records
about the perpetrator. This action yielded
new information about the
perpetrator’s previous interactions with police. Before taking over as risk manager,
S/Sgt. Briers also monitored the Colchester radio channel, but he found
the inci- dent log being maintained on the RCMP’s
Computer integrated information and Dispatching System too clunky and slow to be of great value.
Call-takers, dispatchers, and supervisors also had a shift change at the same
time, and the Operational Communications Centre supervisor, Ms. Jen MacCallum,
remained at the centre until around 7:40 am to make sure the incoming shift was
properly briefed.
At 8:04 am, a “Be on the Lookout”
(BOLO) notice was sent to RCMP members stat- ing that the perpetrator was
“potentially using fully marked ford taurus car number 28B11 and could be
anywhere in the province.” At 8:16 am, RM Briers broadcast a message to all members
that “we’re looking
for potentially a white, fully
marked PC, 28-Bravo-11. Please wear your hard body armour the rest of
the … duration of your shift today. Just in the event you come across this
vehicle.”
The second
RCMP public communication about the critical incident was released at 8:02 am.
The tweet does not mention the replica RCMP cruiser or the possibility that the
perpetrator had left the Portapique area:
Public Communication #2: April 19, 2020 8:02 a.m. Twitter
#RCMPNS remains on scene in #Portapique. This is an active shooter
situation. Residents in the area, stay inside your homes & lock your
doors. Call 911 if there is anyone on your property. You may not see the police
but we are there with you. #Portapique.
By 8:33 am on April 19, the Onslow
Belmont Fire Brigade
hall opened its doors to assist residents who were evacuated
from Portapique. At 9:05 am, the Emergency Response Team began carrying out its
evacuation plan and directing evacuees to the
Onslow fire hall.
CiC West broadcast the location of the comfort
centre over the Colchester RCMP radio channel.
At 8:44 am, Acting Cpl. Heidi
Stevenson of the Enfield RCMP detachment asked the Operational Communications
Centre whether a media release describing the per- petrator’s replica RCMP
cruiser was being released to the public. (Cst. Stevenson was acting corporal to cover this shift.)
S/Sgt. MacCallum had a conversation with Ms. Lia Scanlan, the director of the
RCMP Strategic Communications Unit, at about 8:45 am in which he confirmed that
the replica RCMP cruiser was unaccounted for. He testified that he understood that this information would now be publicly shared.
Ten minutes later, the third tweet
was released. it included a photograph of the per- petrator but did not provide information about the replica
RCMP cruiser:
Public Communication #3 April 19, 2020 8:54
a.m. Twitter 51-year-old [perpetrator’s name] is the suspect
in our active shooter investigation in #Portapique. There are several victims.
He is considered armed & danger-
ous. if you see him, call 911. DO NOT approach. He’s described as a white man, bald, 6'2–6'3 with green eyes.
[photo attached]
At 9:12 am, a similar social media
message was posted by the RCMP on Facebook. A
Department of Natural
Resources helicopter joined
the RCMP response
at 8:45 am.
At 8:50 am, Tom
Bagley left his home on foot for his usual morning walk along Hunter Road.
Known for his kindness, caring, and skill as a storyteller, Mr. Bagley was a
military veteran and retired firefighter. The distance between the Bagley and Jenkins
/ McLeod homes was about 400 metres.
During Mr. Bagley’s
walk, he passed the Jenkins / McLeod residence and would likely
have observed smoke
and fire. Sometime before 9:20 am, Mr. Bagley went to the home, presumably seeking
to assist or to ascertain whether assistance was needed. He was shot and
killed by the perpetrator.
At 9:19 am, Jody MacBurnie called
the Oxford RCMP detachment to express con- cern that he could
not get hold of his neighbours Sean McLeod and Alanna Jenkins. The detachment phone line was
not staffed at that time, and Mr. MacBurnie’s call was put through to 911. Mr. MacBurnie mentioned that Mr. McLeod
knew the perpe- trator, said he was aware of the events
in Portapique, and explained his connection
to Greg Blair. The call-taker replied that he would pass along the information
and that Mr. MacBurnie might get a
call back. This call was not logged on the RCMP’s incident activity
log, and the information shared by Mr. MacBurnie was not dis- patched to the command post or to
responding members.
After taking the lives of Alanna
Jenkins, Sean McLeod, and Tom Bagley, the perpe- trator left 2328 Hunter Road.
At 9:23 am, his replica RCMP cruiser was captured on video travelling south on Hunter Road toward Highway 4, approximately 3.7 kilo-
metres south of the McLeod / Jenkins residence. The perpetrator proceeded along
Highway 4, where he encountered and shot his next victim, Lillian Campbell.
Around 9:00 am on April 19, Ms.
Campbell left her home on Highway 246, in the Wentworth area, for her regular morning
walk south on Highway 4 and along
val- ley Road. Ms. Campbell, who with her husband had retired to Nova
Scotia from the Yukon in 2014, enjoyed
gardening and day trips to nearby beaches.
She was community-minded and loved walking
the roads and parks around
her home in the
Wentworth valley.
Travelling south on Highway
4, the perpetrator passed Ms. Campbell, then turned
the vehicle around and fatally
shot her from his replica
RCMP cruiser. He turned the car around again and continued south
on Highway 4 toward Glenholme.
Mary-Ann and Reginald Jay were Lillian
Campbell’s neighbours. At 9:30 am, Ms. Jay was sewing upstairs in her
home when she heard a gunshot. She looked out
the window and saw an RCMP car slowly turning
around and heading
south, toward Truro. Then she noticed
a body lying on the side of the highway.
Recogniz- ing the clothing, she realized the person on the ground
was Lillian Campbell. She ran outside to the side of the road where
Ms. Campbell was lying and concluded
her friend was dead. She ran back to her house and called 911 to report the incident. The 911 call was placed at 9:35 am.
Ms. Jay gave her husband a blanket to cover Ms. Campbell’s body. As he was doing so, another person, former paramedic
Scott Brumwell, arrived at the side of the road. The 911 call-taker advised Ms.
Jay that both she and her husband should remain inside their residence. Ms.
Jay, unaware of the active shooter situation, responded that it would be
inappropriate to leave their neighbour alone on the side of the road.
Despite the
potential danger, Mr. Jay and Mr. Brumwell remained on Highway 4 with Ms.
Campbell’s body until an RCMP member arrived on scene.
Although the
RCMP command group had some pieces of information earlier, it was not until
approximately 9:40 am on April 19 that they fully grasped that the perpe-
trator had escaped Portapique, that he was driving a very realistic replica
RCMP cruiser, and that he was killing and threatening community members in the
Went- worth and Glenholme areas. What ensued was a scramble on the part of RCMP
members to respond to these new incidents.
The responding
members were at a disadvantage when the critical incident response, which
had been based
on a relatively stationary, possibly
barricaded, and possibly deceased
perpetrator, became a manhunt across
Nova Scotia’s rural
road system. Despite having made some efforts, for example, to account for the perpe- trator’s vehicles, the command group
had not made plans for the possibility that the perpetrator was on the move outside
Portapique. This lack of contingency plan- ning persisted even after the command group became aware that the perpetrator’s
replica RCMP cruiser did not appear to be among the vehicles
found in Portapique. RCMP policies and standard
training offered relatively little guidance about how
best to coordinate a critical incident response to an active mobile threat.
At about 9:42
am, RCMP dispatch broadcast the information from Ms. Jay’s 911 call over the Cumberland radio channel, followed
quickly, at 9:42:30
am, by the Colchester radio channel.
The RCMP Emergency
Response Team, Police Dog Ser- vice, and general duty members
stationed in Portapique and at the Cobequid Pass toll plaza were directed to
respond to the Wentworth area. Additional RCMP mem- bers responded from their
detachments and other
locations. The first-responding RCMP members arrived at
the location where Ms. Campbell was lying at 10:09 am. They confirmed that she
was deceased and contained the scene.
We heard from
RCMP witnesses who were involved in the response on April 18 and 19, 2020, that the shift to a dynamic
incident in which the perpetrator was mobile and his
movements could not be readily predicted presented great challenges to the
entire response. S/Sgt. Bruce Briers explained:
The problem with this [instance] is that we’re
– we were behind the eight ball and so you’re trying to catch up to what of an
individual that knows what they’re planning
on doing, and we don’t
have a clue, and there’s
a lot of areas. So trying to figure out where to best station people in
relation to where he was last seen in the Debert area as opposed
to – and
where he’s going. Because is he going to Halifax or is he going
to some- where else outside
of that area?
Supervisors who were involved in
the critical incident response were unanimous in their testimony that the nature
of the critical incident response
changed signifi- cantly between
9:30 am and 10:00 am on April
19, 2020, when reports started
to come in via 911 of the perpetrator’s actions in Wentworth and
Glenholme.
in this phase of
the critical incident response, members who had been performing assigned supervisory and investigative roles in the command post and elsewhere shifted their location and role in response to information about the perpetrator’s location and activities. in many instances, this shift occurred
without the direction or even necessarily the
knowledge of the critical incident commander and others whose work was integral
to coordinating the overall response. The tasks previously
being performed by these personnel
largely lapsed. At the time when the RCMP
began chasing the perpetrator to Wentworth and Glenholme, there
were eight known or suspected
murder victims in Portapique, and five more had not yet been discovered by the
RCMP.
By 9:40 am, a
draft tweet describing the replica RCMP cruiser and including a photograph of
the vehicle had been prepared by the Strategic Communications Unit and
forwarded to S/Sgt. MacCallum for approval. S/Sgt. MacCallum did not reply, likely because he was responding to the Wentworth
homicide dispatch. The request
for approval was forwarded to Acting insp. Halliday at 9:45 am, and approval was granted at 9:49 am. However, the tweet was not posted
until 10:17 am.
From 9:45 am, the Enfield and indian Brook
members had taken
lookout positions at the border of Colchester
and East Hants counties and were monitoring the Col- chester radio channel. These members had been assigned positions by Acting
Cpl. Stevenson, and she continued to manage the members under her supervision strategically as the mass casualty continued to unfold.
The perpetrator’s replica RCMP cruiser
was captured on surveillance video driv-
ing south on Highway 4 past a residence near Folly Lake between approximately
9:40 am and 9:45 am on April 19, 2020. While the perpetrator was travelling
south, Cpl. Rodney Peterson, the Colchester County duty team leader, was
travelling north on Highway 4 to
respond to the Wentworth scene.
Cpl. Peterson
had learned of the events in Portapique from a phone call with a col- league
before reporting for duty at the Bible Hill detachment at 9:00 am. When he
arrived at the Bible Hill detachment, he met Sgt. O’Brien, who told him they were
looking for a
police car and he should put on his hard body armour. Cpl. Peterson was left
with the impression the perpetrator could be driving a decommissioned police car. At the time of this conversation, the RCMP had possessed a photograph
of the perpetrator’s replica RCMP cruiser for more than an hour.
On his way to
Portapique, Cpl. Peterson had spoken by phone with Cst. Trent Lafferty and Cst.
Adam MacDonald, who were both on his team. Cpl. Peterson learned that multiple
people had been shot in Portapique overnight and that they were looking
for a police car with decals. He understood this information to mean
that the car had once had decals
and traces of them could be seen, but not that
the car was still fully marked. Shortly
after this call, Cpl. Peterson
received a Be on
the Lookout message on his mobile work station that he believed
gave a descrip- tion and a photo of the perpetrator’s vehicle. However, he was unable
to open it. Before opening the BOLO, he heard the call concerning Lillian Campbell’s homi- cide in Wentworth. At about 9:47
am, Cpl. Peterson and the perpetrator passed each other just south
of the intersection of Highway
4 and Plains Road, while
trav- elling in opposite directions.
immediately, Cpl. Peterson
broadcast his sighting of the perpetrator’s replica RCMP cruiser over the Colchester radio channel. He inquired whether
they were looking for a “fully
marked car” or an “ex-police car.” Cpl. Peterson
travelled 1.2 kilometres further
north before finding
a safe spot to turn around, but by then the
perpetrator was no longer in view. Cpl. Peterson travelled
at high speed south of the Highway 104 overpass but could not locate the replica RCMP cruiser. The per-
petrator had driven into Adam and Carole Fishers’ property on Highway 4 and
eluded detection.
At 9:49 am, the
perpetrator turned into the Fishers’ driveway in his replica RCMP cruiser. The
surveillance video shows him exiting the replica RCMP cruiser, reach- ing back into the vehicle via the driver’s
door, and walking toward the residence with what appears to be a rifle in his
right hand. The perpetrator was wearing a baseball hat and a high-visibility
vest.
The Fishers had seen the RCMP Facebook post identifying the perpetrator, and when
they saw him on their
property, they retreated from the window,
hid sepa- rately in the house,
and both called
911. Previously, Mr. Fisher had had a few interac- tions with the perpetrator after
the perpetrator asked him to quote on excavation work on one of his properties. The RCMP had not yet released information to the public about
the perpetrator’s replica RCMP cruiser, but in June 2019, the perpe- trator told Mr. Fisher he had just purchased two decommissioned RCMP cruisers
and was “going to put … one back to a marked, fully
marked car.” Mr. Fisher had called the Bible Hill RCMP detachment with this information at 9:37 am on April 19,
after he saw the RCMP Facebook post.
At 9:50 am,
following the Fishers’ 911 calls, RCMP members en route to the Wentworth
homicide call were redirected to Glenholme. Within six minutes, RCMP members,
including general duty, Police Dog Service, and Emergency Response Team members,
had paused south
of the Fishers’ residence to regroup and confirm
their target destination. They were soon joined by the Emergency Response Team
tactical armoured vehicle.
The Department
of Natural Resources helicopter was directed to Glenholme and began a perimeter
flight around the Fishers’ residence.
The RCMP was unaware that it was already too late: the perpetrator had left the area. The perpetrator did not enter
the Fisher residence, nor did he hide on their prop- erty. Unbeknownst to the Fishers and the RCMP, he had left the property at approxi-
mately 9:51 am. The Fishers
were unaware that the perpetrator had left and believed
he could have been elsewhere
on the property. They remained
hidden in their home.
After leaving
the Fishers’ residence, the perpetrator travelled east on Plains
Road toward Debert. The replica RCMP cruiser was observed by several
civilian witnesses on Plains Road and captured
on multiple surveillance cameras, including just before
9:58
am as it passed Dave’s Service Centre travelling southeast on Plains Road.
Kristen Beaton, a young
wife and mother
who was expecting a child at the time,
was employed by the victorian Order of Nurses (vON) as a continuing care
assistant. She was known for her kindness with her clients. Ms. Beaton was
driving to Mass- town and Debert to meet her homecare clients that morning. Her
cellphone records indicate she was aware of the incident in Portapique and was
actively following the situation, including through social media updates. She
texted with her husband on the topic throughout the morning and had two brief
calls with him. Sometime before 9:00 am, she posted
on a Facebook group called
“Local 35 Home Support
Workers.” The post contained a link to the RCMP Twitter page and the message, “Anyone
working in D5 and 7 please be safe and keep your eyes open.” At 9:38 am, Nicholas (Nick) Beaton sent his wife a Facebook
screenshot of the RCMP warning with a description of the perpetrator, and the two spoke a few minutes later.
Shortly before 10:00 am, Ms. Beaton
parked her Honda
CR-v in a gravel pullout on the south side of Plains Road, just southeast of the Debert Business Park. This pullout
was frequently used by victorian Order of Nurses staff to do paperwork or make
phone calls while making their rounds.
The perpetrator continued travelling on Plains Road to the pullout where Ms. Beaton was parked. He slowed
his vehicle, drove into the pullout, and posi- tioned his replica RCMP cruiser next to her vehicle. He fatally shot Ms. Beaton through her driver-side window.
Heather O’Brien
was driving a volkswagen Jetta on the same stretch of road that Sunday morning.
She had been employed by the victorian Order of Nurses for nearly 17 years as a licensed practical
nurse. She was also a wife and mother.
She was not working that day, but she spoke with her friend and colleague Leona Allen multiple times over the course
of the early morning. The two exchanged
text messages and phone calls about the active shooter situation. Ms.
O’Brien had also been corresponding with her daughters about the events
in Portapique and had
left her home to bring
them coffee.
Ms. O’Brien’s Jetta was captured on the Community Metal surveillance camera, heading southeast toward the
Plains Road pullout, 30 seconds behind the perpe- trator. Ms. O’Brien passed the perpetrator and Ms. Beaton before
pulling her Jetta over to the south shoulder
of Plains Road approximately 260 metres further
on. At that time, Ms. O’Brien was speaking with Ms. Allen by phone. She
told Ms. Allen that she saw what she believed to be a police cruiser and heard
a gunshot.
The perpetrator drove from the Plains
Road pullout and stopped his replica
RCMP cruiser next to Ms. O’Brien’s car. He got out of his vehicle
and fatally shot Ms. O’Brien through her driver-side
window. Her vehicle rolled southeast along the shoulder of Plains Road for approximately 60 metres before
coming to rest in a wooded ditch on the south side of the
road. Ms. Allen heard Ms. O’Brien scream- ing
and the call ended. Ms. Allen immediately tried phoning her back, but her call
was unanswered. At 10:02 am, she called 911 to report that her friend, who was
in Debert in her car, had said “she heard gun shots, and there was a police vehicle and then
all’s i could
hear was her scream.” Other
witnesses also called
911 to report the Plains
Road fatalities.
After the shootings on Plains
Road, the perpetrator proceeded southeast down Plains Road toward exit 13 on Highway 104.
At 10:17
am, more than 12 hours
after Jamie Blair’s
911 call providing information about the perpetrator’s police-decaled cruiser, the RCMP first
alerted the public via Twitter that the perpetrator
was driving a replica RCMP cruiser. Over the fol- lowing hour and a half, the RCMP issued
eight tweets, posted
several Facebook messages,
and issued an email media release.
The 10:17
am tweet included
a photo of the vehicle
with a circle around the fake
28B11 call sign. Posts noting
that the perpetrator was in Central
Onslow or Debert, driving what appeared to be an RCMP vehicle and wearing what appeared to be an RCMP uniform,
were made on Facebook at 10:19 am and Twitter
at 10:21 am.
Shortly after 10:00 am, Richard Ellison
arrived at the Onslow Belmont
Fire Brigade hall comfort
centre. Mr. Ellison entered the fire hall at 10:15 am, after speaking with Cst. Dave Gagnon and Mr. Westlake.
Around the time when Cst. Gagnon
was speaking with Mr. Ellison and Mr. Westlake, RCMP members Cst. Terry Brown
and Cst. Dave Melanson were travelling east on
Highway 2 in search of the perpetrator. When Cst. Brown interviewed Lisa
Banfield at approximately 7:00 am
that morning, he learned that the perpetrator was driv- ing a replica RCMP cruiser that was identical to current RCMP
vehicles and that he was last seen wearing an orange vest. Cst. Brown and Cst.
Melanson also heard a 10:08 am dispatch about the shootings on Plains Road.
They travelled to the Debert area in search of the perpetrator and turned east
on Highway 2 toward Onslow.
Shortly after
10:17 am, Cst. Brown and Cst. Melanson approached the Onslow Belmont Fire
Brigade hall from the west in an unmarked police vehicle, a Nissan Altima. Cst.
Melanson was driving. Both members observed Mr. Westlake wearing an orange reflective vest and standing
next to an RCMP
cruiser. They did not notice Cst. Gagnon in the driver’s seat. Believing Mr. Westlake to be the perpetrator,
Cst. Melanson stopped the car in the middle of the road, approximately 88
metres from the monument at the entrance to the fire hall.
Cst. Gagnon was sitting
in his marked RCMP cruiser,
call number 30B06. Mr. West- lake was standing beside Cst.
Gagnon’s cruiser. The nose of Cst. Gagnon’s vehicle was facing Highway 2, and
the rear of the vehicle was close to a stone monument at the fire hall entrance. Cst. Gagnon’s vehicle
did not have a push bar.
Cst. Gagnon saw
Cst. Brown and Cst. Melanson exit their car, raise their weapons, and point
them in his direction. Cst. Melanson tried to radio to advise members of what
he was seeing, but could not get through. According to Cst. Brown, he yelled
for Mr. Westlake to show his hands. Both Cst. Brown and Cst. Melanson reported
observing Mr. Westlake duck behind the RCMP vehicle. Cst. Brown fired four
rounds from his carbine toward the parked RCMP vehicle, and Cst. Melanson fired
one round from his carbine at the same target.
Mr. Westlake
heard the words “Get down” before shots were fired,
and he started running. He ran into the fire hall and yelled, “Shots fired! Get down! Get down!”
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Onslow Belmont Fire Brigade Hall
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Debert
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Portapique
MacElmon Rd.
Onslow Belmont Fire Brigade
hall
Lower
Onslow
Onslow Belmont Fire Brigade hall
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Onslow Belmont Fire Brigade Fire Chief Greg Muise and Deputy Fire Chief Darrell
Currie were inside with the only evacuee in the building, Richard Ellison. The
four men took cover at the back corner of the fire hall,
behind overturned tables.
hots ify him-
Cst. Gagnon stayed in his cruiser
while the s were fired.
He used his police radio to ident
self and directed the members to look at the call number
on his police
cruiser. He called out, “You guys are pointing your guns at me.” The Colchester
radio transcript also records that he broadcast, “Who are you shooting at? it’s Gagnon.”
Cst. Brown and
Cst. Melanson approached the firehall, spoke with Cst. Gagnon, and performed a
brief scan of the area. After they returned to their vehicle, they phoned their
superior, S/Sgt. Al Carroll, to report the incident. S/Sgt.
Carroll asked a few questions, including
whether they were okay, but because the perpetra-
tor was active, he told them to keep going. Cst. Gagnon reported the incident
to
Sgt. John Kenny, who was not
directly involved in the critical incident response. Sgt. Kenny
offered to have someone relieve
Cst. Gagnon, but he declined. in his words, “Knowing
resources were very limited, i advised i would stay at my post.”
Chief Muise and Deputy Chief
Currie were not yet aware that the person shoot- ing toward the fire hall was an RCMP member. Deputy Chief Currie continued to monitor the perpetrator’s known
movements on the RCMP Twitter
page. The four men
remained hidden for 57 minutes,
until they saw a Twitter
post stating that the
suspect was in Brookfield, which they considered a safe distance from the fire hall.
Sgt. Andy O’Brien and S/Sgt. Carroll travelled
to Portapique at about 10:02 am. S/Sgt. Carroll explained that their purpose
was to ensure continuity of scene con- trol for future evidentiary purposes. Sgt. O’Brien
testified that he did not think
to start a canvass for other victims or witnesses. Standard policing procedures
involve coordinated door-to-door canvasses
to gather eyewitness evidence and to confirm there are no other victims.
This task was not assigned to any RCMP member
that morning. A member who was assigned to perform “a quick drive through
Portapique” to look for anything noteworthy drove along Cobequid Court at around
10:26 am and stopped briefly
in front of the Bond residence. However,
he did not notice
anything amiss. At that time,
the Bonds and the Oliver
/ Tucks had been
dead for 12 hours.
Despite a large police
presence in the community and phone calls
from concerned family
members, the RCMP did not conduct a systematic search of Portapique for
additional fatalities until sometime after 5:30 pm on April 19.
Through the night and into the morning of April 19, the Operational Communica- tions Centre and RCMP detachments at Bible Hill and
Oxford received dozens of calls from
concerned family and community members unable to reach loved ones who may have
been harmed in the unfolding mass casualty. Other people called hospitals and
went to crime scenes seeking information. in most cases, those who placed phone
calls were told that information could not be given out. Many callers were asked
to provide contact
information and told that someone
would return their calls.
Some of these calls were captured in the incident activity log, but oth- ers were not. information about the Portapique fatalities was circulating through family and community networks, including by social
media; for most people, these communications were their main source of
information.
Some family members who could not
get information by calling the RCMP ended up
going to crime scenes to try to learn more. There, some of them encountered
rudeness and threats of violence, including, in some instances, having guns pointed at
them. Other members of the affected communities were also unable to get the
information they needed when they tried to call their local RCMP detach- ment
or 911. Many of these community members also shared information that was
potentially important to the critical incident response, such as when a person
was last in communication or that a missing person knew the perpetrator. This
informa- tion was rarely captured within the incident activity log or
communicated by radio. The failure to provide family and community members with
a clear way to report concerns and share
information also resulted
in additional calls
coming in via 911, at times
competing with more immediately pressing
calls about the ongoing incident.
At 10:14 am, Acting insp. Halliday
advised RM Briers that he (RM Briers) would be responsible for allocating
general duty members to positions to contain the per- petrator. A few minutes
later, CiC West broadcast over Colchester radio that all general duty members were now under the control
of the risk manager.
At approximately
10:15 am, S/Sgt. Daniel (Dan) MacGillivray took over the role of critical incident
commander from S/Sgt.
West, who remained
in the command post to
assist.
The perpetrator
passed through downtown Truro at 10:17 am. This Sunday morning was likely
to have been quieter than usual, with fewer people
out and about.
it was the early days of the
COviD-19 pandemic, and most businesses were closed due to
health regulations. From Truro, the perpetrator proceeded south on Highway 2
and continued through the Millbrook, Hilden, and Brookfield areas toward
Stewiacke and then Shubenacadie. At 10:23 am, his replica
RCMP cruiser was caught by video
surveillance as it passed the Millbrook RCMP detachment.
video footage
from the Millbrook Mi’kmag’ki Trading Post shows the perpetrator in more detail
as he travelled south. He pulled over, exited the replica RCMP cruiser, and
removed a navy-blue jacket, which we believe to be a Correctional Service
Canada jacket. The jacket was later found in Joey Webber’s SUv. The perpetrator
appeared to be wearing a grey RCMP shirt and a baseball cap. He removed the
high-visibility vest from over the jacket and put it on over the RCMP shirt. He
then got back into the vehicle and continued to proceed south on Highway
2 toward the Shubenacadie cloverleaf.
At 10:23 am, RM Briers instructed
Sgt. Marc Rose to set up a roadblock on High- way 104 to stop incoming traffic
to Truro. At this time, RM Briers began to station as many general duty members as possible on major thoroughfares, including on
Highway 4 near Wentworth, west of Truro near the intersection of Highway 102 and Highway 104, and on Highway 102
around Milford and Shubenacadie.
Between 10:26 am
and 10:39 am, the RCMP issued an email media release and posted messages to
Facebook and Twitter noting that further updates on the active shooter
situation would be provided via Twitter.
At 10:37 am, on
instructions from RM Briers, Operational Communications Centre dispatcher Ms. Kirsten Baglee
called Truro Police
Service dispatch and told them to “lock down” the town. Ms. Baglee
then updated Cpl. Edward (Ed) Cormier and insp. Darrin Smith on the
perpetrator’s known movements, vehicles, firearms, and casualties and
reiterated the request to “shut down” the town. Both of these Truro Police
Service officers were unclear about what they were being asked to do.
At 10:39:40 am and 10:40:28 am, while Cpl. Cormier was on the phone with Ms.
Baglee, insp. Smith radioed to all Truro Police Service members to instruct
any- one walking outside to go home
immediately: “[T]ell them there’s an emergency
going on, it’s not safe to be outside … All units just advise everybody
they see to go home. Right now.”
At 10:39 am, RM
Briers requested over Hants East radio that two carbine-trained Enfield members
be sent toward Colchester. Acting Cpl. Stevenson directed Cst. Austin Comeau
and Cst. Christopher (Chris) Gibson to go to Colchester County. They were to
meet in Brookfield, approximately 22 kilometres north of Shubenacadie. She
repositioned other members to account for this change.
At around 10:40 am, radio broadcasts about sightings of the replica
RCMP cruiser suggested that
the perpetrator might be in Brookfield and travelling south on Highway 2. Acting Cpl. Stevenson realized
this information meant that the perpe-
trator could encounter Cst. Chad Morrison at his position
on Highway 2, and she indicated she would move to that position as well.
Cst. Morrison was positioned north of the Shubenacadie cloverleaf and the Shu- benacadie River wearing his hard body armour, his carbine ready, and listening to the radio for updates.
He noticed a Ford Taurus police vehicle
“a couple hundred metres” north of his position, travelling south on Highway
2 toward him.
Acting Cpl.
Stevenson was on Highway 215 south of the Shubenacadie River approaching
Highway 2 when Cst. Morrison inquired over Hants East radio as to who was approaching in a police cruiser. She replied, “That’s
me.” From this posi-
tion, she merged onto Highway 2 in Shubenacadie village and soon thereafter entered
the Shubenacadie cloverleaf.
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Cst. Morrison had begun to put his
vehicle in motion to prepare for a quick exit but was put at ease by Acting
Cpl. Stevenson’s response. instead, he made “a gentle little U-turn”
and pulled his police SUv over on the north side of Highway 224 /
Gays River Road. However, the vehicle that Cst. Morrison saw was in fact the
per- petrator’s replica RCMP cruiser. He did not recognize the perpetrator from
the photos that had been distributed until the vehicle pulled up next to him.
By then, the perpetrator was pointing
a handgun out the driver-side window and began to fire. The perpetrator fired at least three shots, injuring Cst. Morrison. As soon as Cst. Morrison saw the perpetrator, he
“hit the gas” and screamed as he drove off.
As Cst. Morrison sought to escape
the perpetrator and seek medical assistance, Acting
Cpl. Stevenson was accelerating up the eastern ramp of the Shubenacadie
![]()
Collision at Cloverleaf
COMM0007516; labels
added by Mass Casualty Commission
cloverleaf. As she was driving up
the cloverleaf ramp, the perpetrator, who had continued driving south on Highway 2, crossed the bridge. From this vantage point, he would have been able to
see Acting Cpl. Stevenson’s vehicle. He turned left onto the eastern
ramp, across the oncoming lane, and drove against the flow of traffic toward Acting Cpl. Stevenson’s
oncoming vehicle. At 10:49 am, he collided head on with Acting Cpl. Stevenson’s
vehicle near the top of the Shubenacadie cloverleaf ramp.
Acting Cpl.
Stevenson exchanged gunfire with the perpetrator before and after she exited
her vehicle. During the exchange, the perpetrator fired several shots toward
her vehicle. in this exchange, the perpetrator sustained a wound in his fore- head from bullet fragments from Acting Cpl. Stevenson’s firearm.
The perpetrator shot Acting Cpl. Stevenson
at close range, killing her before taking her pistol and
ammunition.
Earlier that
morning, Joey Webber was with his partner, Shanda MacLeod, and their children at their home in Wyses
Corner, approximately 25 kilometres south of Shubenacadie. He was a loving
partner and father who loved being out in the woods. Ms. MacLeod had been
reading about the shootings in Portapique on Facebook and had mentioned them to
Mr. Webber. They discussed the location of
Portapique as being “out past Truro, Debert area” and agreed that what had
happened was “crazy.”
Around 10:52 am,
Mr. Webber drove into the Shubenacadie cloverleaf and came upon the two crashed
police vehicles. He pulled over and exited his car. Witnesses described him as
running to help.
The perpetrator
either directed or forced Mr. Webber into the back seat of the replica RCMP
cruiser, and then shot him. Witnesses observed the perpetrator unloading
items from his replica cruiser and placing them in Mr. Webber’s SUv. He set
the replica RCMP cruiser on fire, and both it and Acting Cpl. Stevenson’s RCMP vehicle were eventually
consumed by the flames.
Despite being
wounded in the exchange of gunfire with Acting Cpl. Stevenson, the perpetrator was able to escape the scene at the Shubenacadie cloverleaf. Around
10:55 am, he drove away in Mr. Webber’s SUv, crossed the oncoming lane of traffic, and proceeded south on Highway
224.
Several
witnesses contacted 911 and provided contemporaneous observations about what
they were seeing at the Shubenacadie cloverleaf.
At around 10:57 am, Emergency Response
Team members arrived
at the Shu- benacadie cloverleaf. They approached with firearms raised,
cleared the replica RCMP cruiser, and realized that the perpetrator was not on
scene. They did not see Mr. Webber’s body in the perpetrator’s vehicle, which
was fully engulfed in flames. Operational Communications Centre dispatchers had
not shared 911 caller reports that a man had been put into the back seat of a police vehicle and shot.
After being shot
and radioing for help, Cst. Morrison continued south over the Shubenacadie
River bridge, driving ahead of the perpetrator in the southbound lane of
Highway 2. He turned right at the cloverleaf onto the western ramp. At the
bottom of the ramp, he turned left and drove west and then south on Highway 2
through Shubenacadie and toward Milford.
On the morning
of April 19, paramedics Molly McFaul and Daniel Storgato were working at the
Milford Emergency Health Services (EHS) base in ambulance M-122. They began their shift at around 7:30 am, and both had little information about the events of the night before. They
were advised by dispatch to remain inside the base and avoid any unnecessary
travel.
At 10:51 am, an Operational Communications Centre dispatcher called
EHS dis- patch to report that
Cst. Morrison had been shot and was at the Milford base. This message appears
to have been misunderstood by EHS dispatch. At 10:55 am, EHS dispatch sent Ms.
McFaul and Mr. Storgato a dispatch ticket advising them that an RCMP member
required treatment. They were told to remain
at the base as the member was en route.
They waited in the ambulance bay for the member to arrive.
Cst. Morrison
was experiencing a loss of feeling in his hands and was losing grip strength. He realized he would no longer be able to fire his weapon. He went to the
back of the EHS building, “wrestled” the magazine
out of his carbine, and hid it in
the grass. He was experiencing blood loss from a bullet
wound in the inner crook of
his left arm. Another bullet
had entered one side of his right
arm, fractured his ulna
bone, and exited on the other side. He huddled
down in a grassy, marshy area
beside the EHS base and waited for someone to find him.
Shortly thereafter, EHS dispatch contacted
the paramedics and advised them to look outside for a vehicle. The
paramedics located and treated Cst. Morrison and transported him to hospital.
Before leaving, they advised EHS dispatch that
Cst. Morrison’s RCMP vehicle would be left at the EHS base and that
there was an empty carbine behind the building.
Sgt. Darren Bernard, commander of the
Millbrook detachment, was the first general duty member to arrive at the
Shubenacadie cloverleaf scene. He arrived approxi- mately four minutes after
the Emergency Response Team members had left. Like other responding members, Sgt. Bernard did not receive an
adequate briefing on the morning of April 19. He did not realize that the
Emergency Response Team had been on scene. Cst. Comeau,
Cst. Jared Daley, and Cst. Gibson were travelling right behind Sgt. Bernard, in separate
cars. Within the next few minutes, they too arrived on scene and observed the
two police vehicles engulfed in flames. Cst. Comeau pulled up alongside Sgt.
Bernard and called out to him that Acting Cpl. Stevenson was on the ground.
Sgt. Bernard confirmed that Acting Cpl. Stevenson was dead and stayed with her body while broadcasting details of the scene. Sgt. Bernard
looked for Acting Cpl. Stevenson’s firearms and radio, and aired his findings
over Hants East radio. A delay in
patching radio channels interfered with the receipt of this information by
other responding members.
Sgt. Bernard,
who is Mi’kmaw, stayed with Acting Cpl. Stevenson. He later explained to the
Commission: “[W]e just kind of sat down in the dirt and stayed with Heidi. in my culture,
you know, when there’s a deceased person, you have to stay with them. So, i kind of stayed with her and just sat in the dirt for i don’t know how
long.”
The perpetrator left the
Shubenacadie cloverleaf at approximately 10:55 am, driv- ing south on Highway
224 in Mr. Webber’s SUv. He passed Gina Goulet’s home on Highway 224, made a
U-turn, and drove back to her residence. He parked behind the residence, where
the SUv was partly obscured from the road, and broke glass in a side door to enter the residence.
Ms. Goulet was
a professional denturist and a cancer survivor. She lived in, and loved, rural
Nova Scotia. in 2020, she had been a denturist for 27 years.
She had met the perpetrator through
the province’s relatively small denturist community, including through
continuing education activities.
That morning,
Ms. Goulet had been communicating with her daughter Amelia Butler by text
message. They discussed what they had heard of the incident in Portapique, which by that time was being discussed
on various news networks
and social media. Ms. Goulet told Ms. Butler that she knew the perpetrator and that another denturist
had warned her to keep her doors locked. She said she was scared because the perpetrator
knew where she lived. Ms. Butler reassured her
mother that “there’s no way he could get that far without being caught.” She
agreed to keep her phone close in case Ms. Goulet called.
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At around 10:58
am, Ms. Goulet called Ms. Butler. Ms. Butler explained that her cell- phone rang twice, but as she picked up the phone, the caller hung up. Ms. Butler tried to phone her mother back multiple times
but received no answer. Ms. Butler
and her husband, David, were increasingly alarmed,
so they left their residence and drove toward Ms. Goulet’s home.
The perpetrator went into the living area, where he shot one of Ms. Goulet’s two dogs. He then went into the master
bedroom and fatally shot Ms. Goulet, who was hiding in the ensuite bathroom. He
left the residence in Ms. Goulet’s grey Mazda 3 hatchback.
By the time the
Butlers entered Shubenacadie, a roadblock had been set up by the RCMP to contain the Shubenacadie
cloverleaf scene. The detour added approximately 10 to 15 minutes to their
drive. They arrived at the Goulet residence at 11:55 am. Ms. Butler called 911
shortly after they arrived. Mr. Butler went inside the house. As he turned toward the hallway, he saw a small
silver shell casing and thought he saw blood and what he believed was a body.
While Ms. Butler was on the phone with 911, the Butlers left Ms. Goulet’s
residence to find help. They headed north on Highway 224 toward the
police roadblocks at Shubenacadie. At
around 12:00 pm, Mr. Butler flagged down Cst. Comeau, who was on his way back to the Enfield detachment after being relieved
at the Shu- benacadie cloverleaf scene. The constable had been instructed
to leave because he was a colleague and friend of Acting Cpl. Stevenson. Mr.
Butler exited his vehi- cle and told Cst. Comeau
what he had seen at Ms. Goulet’s
residence.
The RCMP
Emergency Response Team had left the Shubenacadie cloverleaf at approximately
11:00 am in pursuit of the perpetrator on Highway 224. Either during the period
in which the perpetrator was inside Ms. Goulet’s home or sometime shortly after
he left, ERT members drove southbound past the Goulet residence. RCMP members
did not see Mr. Webber’s SUv parked behind Ms. Goulet’s home.
By this point
in the critical incident response, the RCMP had shared information about the perpetrator’s disguise
and the replica RCMP cruiser
with the public. As the morning progressed, more
Nova Scotia residents were aware of the mass casualty and that the perpetrator
was no longer in Portapique. This knowledge produced an increase in 911 calls,
including reported sightings of legitimate RCMP vehicles that members of the
public believed might be the replica RCMP cruiser. The Operational Communications Centre dealt efficiently with
these calls, for the most part resolving them by checking the caller’s location
against the mapping of marked RCMP vehicles provided by the Computer integrated
information and Dis- patching System.
As might be expected, some of the information shared
by the public proved true, while other information was shown at the time or subsequently to be inaccurate. For example,
a community member called 911 reporting a possible sighting of the perpetrator
at the Sobeys grocery store in Truro. This information was relayed to the RCMP
command post and dispatched to members. Other information – includ- ing the
timing, the information received from witnesses in the area, and the per- petrator’s
known direction of travel – contributed to the belief among Emergency
Response Team members
that the perpetrator was still in the Elmsdale
area rather than in Truro. The
J Division (New Brunswick) RCMP ERT Team and Truro Police Service officers responded to the Sobeys
tip in Truro, while the H Division (Nova Scotia) ERT checked out the Sobeys in
Elmsdale, in case there was a mistake about the location. Both teams reported that the areas were clear.
The RCMP H Division
Emergency Management Section
operates the Divisional Emergency Operations
Centre – a coordination centre that is “stood up” or activated
when required in an emergency. it was not activated during the mass casualty. There had, however, been conversations between provincial Emergency Management Office personnel and the RCMP about the availability of the Alert Ready messaging system on the morning of April
19.
At 11:14 am, Mr. Michael Bennett, the
Emergency Management Office’s incident commander, called Mr. Glenn Mason, the civilian manager
of the RCMP Emer- gency
Management Section, to advise that the Emergency Management Office incident command
was prepared and ready to use Alert Ready on request by the RCMP. RCMP Operational Communications Centre staff, the command
group, and the executive leadership told the Commission that, on April
19, they were not aware that Alert Ready was a mechanism by which information could be shared directly
with the public during a critical incident.
This lack of knowl-
edge was at least partly due to historical decisions
made by the RCMP about Alert Ready.
Mr. Mason called the Operational
Communications Centre to inquire whether the RCMP wanted a public alert sent via the Alert Ready system. After a brief tele-
phone exchange, S/Sgt. Steven (Steve) Ettinger told Mr. Mason to go ahead with
a public alert. The direction was to use “the bare minimum.” Mr. Mason relayed
this information to Mr. Bennett at
11:21 am. As we set out in the next section, the perpe- trator was killed at
11:26 am. No Alert Ready messages were broadcast in relation to the mass casualty.
At 11:16 am,
about four minutes after the false sighting at Sobeys, the perpetrator pulled into the Elmsdale
Petro-Canada station and parked Ms. Goulet’s grey Mazda
3 at pump 7. He was captured on video surveillance at this location. He briefly
reached toward the passenger seat of the Mazda 3 before exiting the vehicle.
Almost simultaneously, Cst. Andrew Ryan,
Cst. Jason Barnhill, and Cst. Brent
Kelly of the H Division Emergency Response Team parked their vehicle at
pump 8 of the same gas station. Canopy pillars stood between the two vehicles.
The nose of the ERT vehicle was pointing in the opposite direction of the nose
of the Mazda
3. The three constables exited the ERT vehicle just as the perpetrator was picking
up the fuel hose at pump 7. All three members were dressed in tactical gear.
After
replacing the fuel hose, the perpetrator got back into the Mazda 3. He pulled forward
and turned sharply to his right, making a 180-degree turn to pull up to pump 5. There were now two sets of fuel pumps and canopy pillars between
the Mazda 3 and the ERT vehicle. After a brief pause at this pump, the perpetrator
drove out of the parking lot without having
obtained fuel. His approximate time of departure from the Petro-Canada
station was 11:17:05 am, 44 seconds after his arrival. After leaving the gas station,
the perpetrator travelled
south on Highway 102 to Enfield.
At 11:24 am on April 19, the perpetrator arrived at the Enfield Big Stop gas station
from Highway 2, after turning off Highway 102.
The Enfield
Big Stop surveillance videos show that the perpetrator initially pulled in next
to pump 7 and then drove around
to pump 5 at 11:24
am. He parked the Mazda 3 but remained in the vehicle. Less
than 30 seconds later, RCMP Police Dog Service member Cst. Craig Hubley,
travelling with Emergency Response Team member Cst. Ben MacLeod, parked his
unmarked RCMP SUv at pump 6. The gas pump and a canopy pillar were between them
and the Mazda 3.
As he was exiting
his vehicle, Cst. Hubley noticed
a lone man slouching over in the driver’s seat of the grey vehicle
on the other side of the pump. He recognized the perpetrator from the photographs he had reviewed that
morning and observed his demeanour and head wound. The two were about 15 feet apart.
As he drew his pis- tol
and pointed it at the perpetrator, Cst. Hubley shouted
“it’s him” to Cst.
MacLeod.
Cst. Hubley saw the perpetrator react by “jerking
back while seated and immedi- ately rais[ing] a silver coloured
pistol in my direction with his right hand.”
Both Cst. Hubley
and Cst. MacLeod testified that they followed their training, shooting multiple
rounds in a short period of time to ensure the threat presented
by the perpetrator was addressed. After firing these rounds, the two members
moved to the passenger side of their
vehicle, using the engine block
as a barrier in case the perpetrator was still able to shoot them.
The surveillance video shows that as Cst. Hubley approached the Mazda 3, the
perpetrator changed his posi- tion in the vehicle. The Mazda 3 made a rocking
motion, and the windows of the vehicle remained intact during this motion. We find
in volume 2, What Happened, that the rocking motion was caused by the
perpetrator discharging his firearm, shooting himself in the head just before
or at the time when the RCMP members fired on him. The autopsy
showed that the immediate cause of death was the
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Route to Enfield
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multiple bullets
fired by Cst. Hubley and Cst. MacLeod, which caused lethal dam- age to the
perpetrator’s internal organs.
Cst. Hubley
broadcast the perpetrator’s death at 11:27:12 am on the ERT radio channel.
At 11:40 am,
the RCMP issued its last tweet of the mass casualty, stating that the
perpetrator was “in custody.” This information was posted on Facebook at 11:41 am.
The Serious
incident Response Team investigates all serious incidents that arise from the actions of police in Nova Scotia. The team carried out two investigations arising from the RCMP’s
response on April 18 and 19: one into the perpetrator’s death, and the other into the Onslow fire hall shooting.
in the wake of the mass casualty, the RCMP prioritized institutional and investiga- tive imperatives over the needs
of survivors and family members and over pub- lic demands for information. This
prioritization led to serious shortcomings in the RCMP’s information-sharing
practices.
Next of kin
notifications were not always provided to families in a manner con- sistent
with RCMP policies. Concerns raised by family members include that noti-
fications were not carried out as quickly as possible and that in some cases
the notifications were done poorly. During and after the mass casualty, some
next of kin notifications were
provided on roadsides or near crime scenes, because family members came to the
place where their loved ones had died. Other family mem- bers experienced a
delay before they received a next of kin notification.
Some of these challenges are attributable to
the magnitude of the critical incident, but many of the difficulties were
systemic rather than situational. There was no coordinated and adequately resourced plan to carry out this important
function. in addition, gaps in the RCMP policy and guidelines meant that not all members were adequately trained to carry out these duties with the required sensitivity. The inadequate handling of next of kin notifications caused additional distress
to fam- ily members. in some
instances, it led family members to begin questioning the RCMP’s response at
this important juncture of transitioning from critical incident to major case
investigation.
The RCMP H Division
and Nova Scotia victim Services
had responsibility for meet-
ing the information and support needs of survivors and surviving families. They
were unprepared for the immense
need in the aftermath of the mass casualty for family liaison and a range of support
services. Attempts were made to adapt exist- ing services to these
needs, but, despite
the best efforts
of individual service
pro- viders, these attempts fell short. Service providers were unable to
scale up their services to meet the heightened demand, and the resultant gaps
showed a lack of institutional preparation and coordination for an incident
of this scale.
The RCMP appointed one person, Cst. Wayne (Skipper)
Bent, to act as liaison for all the families
of those whose lives were taken, aside from the family of Cst.
Stevenson. These families were not well served by the decision to have a single
RCMP liaison. While some families expressed appreciation for Cst. Bent’s work,
he was often overwhelmed by his job. Every aspect of his role was undefined by
pol- icy or direction from superiors, including
to whom he was responsible to provide
information (for example, which survivors); what information he was supposed
to share; and with what frequency. He had received
no formal training
and, at the time, none existed. Other RCMP officers
said they had some experience working with families, but not at this scale.
The families were also disserved by the RCMP’s decision to require them to choose only one representative for the RCMP to deal
with. This decision placed the respon- sibility to convey difficult
information – and to advocate
for more information – on a single family
member, thereby placing a great burden on that representative. This approach
was untenable when family members did not agree about how best to engage with the RCMP or when there was conflict within
families. Both these
cir- cumstances were predictable manifestations of the traumatic grief
experienced by family members who were bereaved in these circumstances, and not reflective of the families
themselves. This approach
also did not recognize that families might have different people who might need different information or that an individual
family member’s capacity to serve as liaison might change over time. in short,
it was an approach that was not well suited to the delicate work of supporting fami- lies in the wake of a mass casualty.
Lisa Banfield
also experienced problems in accessing services. After she was criminally charged,
Ms. Banfield and her family stopped receiving
information or services from Cst. Bent.
She was not provided with another RCMP liaison.
in accordance with the RCMP’s Critically
Injured and Fallen Member Guide, ser- vices were provided to the family of Cst. Stevenson by the
RCMP, veteran Services, and victim Services, and they were assisted by Cst.
Randy Slawter and Cpl. Ron Robinson. Cst. Morrison
also received information and support consistent with this guide. There
is no equivalent policy or definition for family liaisons
in the deaths of civilians.
Crime scenes
and evidence were not always treated with care. in some instances, evidence was
overlooked by RCMP investigators but found by civilians, including family
members of those whose lives were taken. in another instance, evidence was returned to family members without
being cleaned and without warning that biological matter had not been removed.
The RCMP directed the Nova Scotia Medical Examiner Service not to release infor- mation to families
of those whose lives were taken, including
about the manner of
death. This direction was unnecessary in the circumstances of this
investigation, and in some instances it exacerbated
family members’ grief and mistrust. After the
Commission became aware of this directive, we took steps to ensure it was lifted.
The Commission connected those families who wished to learn more with the Med- ical
Examiner Service so they could receive information about their loved ones’ deaths and have their questions
answered privately and directly.
in short, the
RCMP did not share all the information it had either publicly or with family
members. The reasons for not sharing information were not always clear. Some improvements were made after
Jennifer Zahl Bruland,
the oldest daughter of John Zahl, advocated that families should
receive information from the RCMP directly before it was shared
publicly by the media. However, problems continued to arise.
in the days and weeks after April 18 and 19, 2020, the mass casualty
was the leading Canadian news story for mainstream media outlets. it also received
international media attention. Members
of the public looked to the RCMP and to civic leader- ship for reassurance and for information. They were disappointed by the RCMP’s public communications on both
counts – starting with the first press conference on April 19, 2020, and continuing
until the federal and provincial
governments announced a review of (and subsequent inquiry into) the
response to the mass casualty.
Some degree of uncertainty was to be expected in the immediate
aftermath of the mass
casualty, and the media was initially understanding about the challenges fac- ing the RCMP as it commenced its investigative work on multiple
complex crime scenes across a
wide geographic area. Given the gaps in the information provided by the RCMP,
however, journalists soon turned to other sources, particularly com- munity
and family members,
to understand the chronology of the mass casualty,
identify victims, learn more about the perpetrator, and describe the RCMP’s
critical incident response.
As concerns
arose about seemingly changing or incomplete information being provided by the RCMP, media and public scrutiny
began to focus on the quality
of the RCMP’s critical incident response and its public communication practices
during and after the mass casualty. Family and community members began pub-
licly expressing frustration at the relative lack of information being shared
by the RCMP. For example, Nick Beaton, the spouse of Kristen Beaton, who was
expecting a child at the time she was killed by the perpetrator on April 19,
2020, was quoted by the Canadian
Press on April 27: “We don’t know anything because they’re not telling us
anything.”
By the time of
the RCMP’s press conference on April 28, 2020, the media was actively investigating
several issues potentially arising from the mass casualty, including public communications during the critical
incident response and the
role of misogyny and violence
against women in the mass casualty. Media and
the National Firearms Association were also pursuing more information about the
types and origins of firearms used by the perpetrator in the mass casualty.
H Division
leadership and communications personnel experienced considerable personal and professional strain in the aftermath of the mass casualty. At the
same time, the RCMP’s most senior leaders, particularly Commr. Brenda Lucki and
D/Commr. Brian Brennan, were concerned by what they perceived to be inade-
quate internal briefing practices and poor public communications.
inside the
RCMP, internal communication challenges persisted between H Division and national
headquarters and within national headquarters itself. H Division
was providing fewer internal
briefings to national
headquarters than expected,
given the scale of the mass casualty, and H Division
appeared slow to provide informa- tion requested by national
headquarters, including some information that had been requested by Bill Blair,
who, as minister of public safety and emergency preparedness at the time, was
the responsible minister for the RCMP. A request made by H Division’s director of strategic
communications for more support went unfulfilled for some weeks as public
health measures associated with the COviD-19 pandemic made national headquarters hesitant to send additional communica- tions staff to Nova Scotia.
These dynamics
came to a head in the teleconference of April 28, 2020, among nine senior RCMP personnel, five from national
headquarters and four from
H Division, at which Commr. Lucki expressed her disappointment and frustration about how public communications and internal briefings
had been managed
in the days since
the mass casualty. She explained to the Commission that this meeting reflected “a buildup of
frustration” about the problems with public and internal communications. in her
words, the purpose of the meeting was to “outline my expectations. i wanted to outline where i felt things weren’t going well.” During the
meeting, Commr. Lucki expressed her disappointment and suggested that the RCMP’s
inability to promptly deliver information to the responsible minister and the prime minister reflected
poorly on the organization. She also emphasized that when the RCMP is not forthcoming with information, the
public will look to other sources for answers.
Commr. Lucki
specifically addressed the fact that information about the perpetra- tor’s firearms
had not been included in the press conference that day. She stated
she had received a request
from Mr. Blair’s
office as to whether that information
would be forthcoming and had “shared with the Minister
that in fact it was going
to be included in the news release,
and it wasn’t.” She requested
an explanation for why she had been told that information
about the perpetrator’s firearms would be included in the press conference when that was incorrect. National headquarters
staff explained that it had been a misunderstanding on their part. Ms. Lia Scanlan,
director of the H Division Strategic Communications Unit, advised Commr. Lucki
that, more than two hours before the press conference, she had told D/Commr.
Brennan what information the investigative team felt able to share. He had not
passed on this information to the commissioner.
in this same context,
Commr. Lucki referred
to firearms legislation, identifying that legislation
then proposed by the federal government “is supposed to actually help police.” We conclude in volume 5, Policing, that Commr. Lucki’s
audio recorded remarks about
the benefits to police of proposed firearms legislation were ill- timed and
poorly expressed, but they were not partisan and they do not show that there had been attempted
political interference. However,
the April 28 meeting
both reflected and contributed to the deterioration of the relationship between H Division and RCMP national
headquarters after the mass casualty.
The RCMP
response to the federal-provincial announcement of an independent review (and subsequent inquiry)
was to stop sharing information almost entirely, on
the basis that it was inappropriate to do so while a review or an inquiry was ongoing.
We provide
a more detailed account of the RCMP’s
actions after the mass casualty in Part B of volume 5 of this
Report.
The Province of Nova Scotia made funding for individual counselling available to survivors and family members
of those whose
lives were taken
through the Crimi- nal injuries Counselling Program
administered by Nova Scotia victim Services. The fund normally requires that there be an ongoing criminal case and caps the fund- ing,
but in some instances, victim Services relaxed these rules to help victims of
the mass casualty.
Some of those most affected
found the process
to access this funding smooth, while others found it
challenging.
After the mass casualty,
Nova Scotia victim Services established the Stronger Together
support navigation program and opened three community support nav- igation centres
– in Portapique, Debert, and Shubenacadie. in early June 2020, a fourth
centre was opened in Wentworth. These centres were intended to provide
support for families and individuals in the four most affected
communities.
Despite this thoughtful initiative, many people reported experiencing difficulties in navigating support
systems to access the services
they required. Problems
included being provided a list of support services that was outdated and
included irrelevant services. Most fundamentally, those most affected reported
they had to seek out support
services. Numerous counsellors on the lists
were simply not tak-
ing new clients at all, so some family members
made many calls
before finding someone who would accept
them. Many were overwhelmed by having to navigate
multiple systems.
Those who were
out of province and out of country faced substantial hurdles in accessing
funding from Nova Scotia victim Services. For example, Crystal Mendiuk, who
lives in Alberta, described her and her family’s experience as a “continual uphill battle.” Her entire family had
“enormous … difficulties in getting approved for the program.”
in September 2022, Mr. Joudrey and his Portapique neighbour Mallory Colpitts attended a consultation with the
Commission in which they reflected on their expe- rience of seeking support. Mr. Joudrey observed, and Ms. Colpitts agreed, that while
mental health services
were made available
to them, they found it hard to recover while continuing to live in Portapique. Ms. Colpitts reflected, “[H]ealing or attempting
to heal in a place that contributed to a sickness is not easy.” Both these residents would
have preferred to relocate, even temporarily, for the sake of their mental health, but no financial
assistance was available to support them to do so.
On April 18 and
19, 2020, the perpetrator took the lives of 22 people (one of whom was
expecting a child at the time), physically injured three others, and inflicted
lasting harm on the people,
families, and communities who were most affected
by his actions. in the early days of the COviD-19 pandemic, Nova Scotians’
sense of safety was rocked by the
mass casualty. The ripples of this incident extended across Canada and well
beyond. in the weeks and months after the April 2020 mass casualty, those most affected, Nova Scotians, and the
Canadian public were shaken further by revelations about the RCMP’s apparent
lack of preparedness for a critical incident response of this scale.
Our mandate
directed us to consider the context, causes, and circumstances of the mass
casualty. Our work revealed that the antecedents of the mass casualty ran deep
into the perpetrator’s history of violence and misconduct. This history, in
turn, reflects the broader context
of our collective social and institutional failures to perceive and respond
effectively to gender-based, intimate partner, and family violence. Such
failures extend well beyond this perpetrator.
We found that there is a close connection between gender-based, intimate
partner, and family violence – in which the perpetrator engaged throughout his adult life – and the rarer phenomenon of mass casualty
incidents.
We also looked closely
at the aftermath of the April 2020 mass casualty: consider- ing how the most affected families and communities were supported as they nav- igated
their grief and trauma; evaluating the RCMP’s work in the days, weeks, and months after
the mass casualty; and looking for lessons that we could
learn from this mass casualty to help keep Canadian communities safer in the future.
This Final Report documents what we have learned.
PART C: THE MASS CASUALTY COMMISSION
The Mass
Casualty Commission was an independent public inquiry created to examine the
April 2020 mass casualty in Nova Scotia and to provide meaningful
recommendations to help keep communities safer.
The Commission’s mandate was set
out under the authority of the governments of Canada and Nova Scotia in
accordance with both federal and provincial pub- lic inquiry statutes. The details of the mandate
were written in official documents known as Orders in Council. These
Orders in Council
set the terms
of reference as well as the expected outcomes and the time frame within which the work must be
accomplished.
Our role as Commissioners was not
to determine guilt or assign blame. Our choice was to blame or to learn – and
we chose to learn. We were required to establish what happened leading up to, during, and after the mass
casualty; to review cer- tain defined issues
to understand how and why the mass casualty occurred; and to produce a report that included findings, lessons
learned, and recommendations to help keep Canadian communities safer in the future. in addition to inquiring
into what happened, we were directed to explore the causes, context,
and circum- stances that gave
rise to the mass casualty; the responses of police, including the Royal
Canadian Mounted Police, municipal police forces, the Canada Border Ser- vices
Agency, the Criminal intelligence Service Nova Scotia, the Canadian Firearms Program, and the Alert Ready Program;
and the steps taken to inform, support, and engage those most affected.
We were also directed to examine a number of specific, related issues,
including:
i)
contributing and contextual factors,
including the role of gender-based and intimate partner
violence;
ii)
access to firearms;
iii)
interactions with police, including any specific relationship between the perpetrator and the RCMP and between
the perpetrator and social
services, including mental health services,
prior to the event and the
outcomes of those interactions;
iv)
police actions,
including operational tactics,
response, decision-making,
and supervision;
v)
communications with
the public during and after the event, including the appropriate use of the
public alerting system under the Alert Ready Program;
vi)
communications between
and within the RCMP, municipal police forces, the
Canada Border Services Agency, the Criminal intelligence Service Nova Scotia,
the Canadian Firearms Program, and the Alert Ready Program;
vii)
police policies,
procedures, and training
in respect of gender-based and intimate partner violence;
viii)
police policies, procedures, and training
in respect of active shooter incidents;
ix)
policies with respect to the disposal
of police vehicles
and any associated equipment, kit, and clothing;
x)
policies with respect
to police response to reports of the possession of prohibited firearms,
including communications between
law enforcement agencies; and
xi)
information and
support provided to the families of victims, affected citizens, police
personnel, and the community.
These instructions meant that we were to establish a factual foundation through our independent investigation as well as to undertake significant public policy and research
tasks.
We encourage readers to learn more about the Commission’s
mandate and Orders in Council in Volume 7, Process.
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Mandate
![]()
in addition to outlining
the mandate for our work, our terms of reference
also directed us to:
• adopt any procedures or methods we consider expedient
and proper to carry
out our work;
• be
guided by restorative principles in order to do no further harm, be trauma-
informed, and be attentive to the needs of and impacts on those most directly
affected and harmed;
• give particular consideration to
people or groups
who may have been
differentially impacted; and
• consider relevant previous reviews and recommendations.
Restorative principles require a non-adversarial, inclusive, and collaborative
approach. They oblige us to focus on facts and issues in context rather than in
isolation, and on accountability and responsibility rather
than on liability or blame. These principles underscore that in seeking answers, we can develop clear under-
standings, acknowledge harms done, and develop practical
reforms. This approach was consistent with other recent
commissions and is also consistent with a wide range of initiatives in Nova Scotia that regularly
engage restorative principles.
Restorative
principles guided the work of the inquiry
to understand how and why the mass casualty happened,
but they did not shape or change the inquiry’s
purpose or mandate.
Trauma-informed in this case meant understanding the exist- ing trauma
and taking it into account
as we pursued our mandate;
it could not and
did not impede our pursuit of the mandate. it informed us in order to approach our work in a way that would
enable people to participate in the best manner possible to get at the information required.
This approach, combined
with the nature of a public inquiry as a flexible process,
meant that we were able to create processes – and sometimes adjust them as we went on – to try to minimize the ways in which
the Commission might cause further harm.
As described in detail
in volume 7, we used several approaches to achieve this goal,
always with an unwavering commitment to get the facts, answers, and best infor- mation,
and ultimately to develop our recommendations. They included paying attention to those identified as differentially impacted
by the mass casualty and seeking out and valuing
knowledge and input
from individuals and groups with different lived experiences. This
approach also flowed from the direction to us to attend to past reports and reviews, many of which indicate that
actions related to aspects of our mandate, such as policing
and gender-based violence, can have dis- proportionate effects on
differentially impacted people and groups. We therefore sought input in framing
recommendations to avoid inadvertently deepening struc- tural inequalities.
Our objective was to find out what happened
and how and why it happened so that
we could distill
the lessons learned
from the mass casualty and make recom- mendations to help ensure the safety of our communities in the future. Throughout
our mandate, we endeavoured to create conditions that would encourage
those who had a direct and substantial interest
or relevant information to engage with our work and participate in our
efforts to achieve these goals. To that end, we adopted an inclusive,
restorative approach rather than a divisive, adversarial one, in the hope that those entrusted with the effectiveness of our institutions and sys- tems will,
going forward, continue to operate in this same spirit of individual and
collective responsibility.
To deliver on
the Commission’s three-part mandate, we developed a series of three overlapping
phases that built on each other, starting with establishing a factual
foundation of what happened, followed by an exploration of how and why it hap- pened, which all led to developing our findings and
recommendations.
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in Phase
1, the Commission focused on ascertaining the facts and establishing what happened leading up to, during, and
after the mass casualty. Building the core foundation of evidence was necessary
not only to answer the public’s pressing questions about the mass casualty but
also to lay the foundation for completing Phases 2 and 3 of our mandate.
in Phase 2, we
examined the causes, context, and circumstances of the mass casualty in order
to answer questions about how and why it occurred and to understand the facts
in the broader context. in this phase, we focused in particular on exploring
issues set out in our Orders in Council, such as best practices for critical incident responses, public
communication, supporting individuals and communities after a mass casualty,
gender-based and intimate partner violence, and access to firearms.
in Phase 3, we
looked forward and focused on what lessons could be learned and how best to
make a difference in the future. We consulted with many people, including those most affected,
Participants, experts, and members of the public.
in addition to
this phased approach, we organized the Commission’s work around three main
themes or pillars: violence, Community, and Policing. This thematic
organization helped to connect the dots among specific facts, incidents, issues, contexts, causes, circumstances,
and consequences.
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in exploring
these themes in detail, the Commission’s work included the following
tasks:
• A review of tens of thousands of documents, videos,
and audio files
gathered through subpoenas from the RCMP and others.
• A
thorough, independent investigation carried out by Commission specialists and counsel involving
multiple site visits and interviews with over 230 people,
including more than 80 RCMP officers.
• Regular input
and submissions from 61 Participants, including those most affected, emergency responders, and groups with relevant subject-matter expertise.
• Sharing 31 Foundational Documents that efficiently
organized, analyzed, and distributed the information we gathered through
our investigations. Participants
were invited to review the Foundational Documents, and their input was incorporated
before the documents were shared during public proceedings. The Foundational Documents are supported by more than 6,000 source materials and
additional exhibits.
• Hearing
from 60 witnesses during public proceedings. These witnesses included more than 30 RCMP members,
including the senior officers who were in charge in Nova Scotia
and at the national level at the time of the mass casualty.
• Sharing
22 commissioned reports prepared by independent experts which focused on the
related issues in our mandate and drew on key government and policy structures
as well as on academic research and lessons learned from previous mass
casualties. The commissioned reports were supported by more than 1,100
documents of supporting research and policy.
• Environmental scans of past Canadian
and international reviews
and inquiries that dealt
with the matters
within our mandate.
• Organizing
more than 20 roundtables and other kinds of discussions during public
proceedings. During the roundtables, we heard from more than 100 experts and others with relevant experience to share, some of them local and others bringing Canadian and
international perspectives.
• Providing
information about our work to the public and listening to them to understand
the impact of the mass casualty and to assist us in setting our priorities and
making recommendations.
• Receiving
submissions from more than 900 members of the public, who shared personal
experiences of the mass casualty
and recommendations for relevant research and suggestions for
change.
See
Volume 7 of the Final Report for more information about the Commission’s
approach and process.
PART D: THE FINAL REPORT – AN OVERVIEW
The Final Report is the culmination of the Commission’s independent two-and-a-
half-year investigation into the mass casualty, setting
out what happened
as well as the underlying
causes, context, and circumstances.
The Report includes our findings of what happened,
helping to answer questions
from those involved and from the public. it also includes lessons learned,
which capture knowledge gained based on past outcomes and experiences.
The Report
includes a set of recommendations that people across our govern- ments,
institutions, and communities can begin to take action
on right away. Our recommendations cover a wide range of areas, including:
• how to strengthen community safety and well-being, including
through focusing more on gender-based, intimate partner, and family violence;
• best practices
for critical incident responses;
• how to improve public
communication during an emergency;
• how to better support individuals, families, emergency
responders, service providers, and communities after a mass casualty;
• how the RCMP can rebuild public trust and deliver effective,
rights-regarding policing services in Canadian communities;
• how policing
in Nova Scotia may be improved in the near term, and how
the Nova Scotian community should be engaged
in imagining the future
structure of police services in the province;
• how to improve everyday policing practices in Canada; and
• how to more safely manage access
to firearms and police paraphernalia.
We conclude
that preventing mass casualties requires a holistic, public health approach that addresses root causes, including poverty and inequality, and focuses
primarily on prevention and early intervention in patterns of behaviour that cause
harm and have the potential to escalate to mass violence.
Prevention requires active and concerted “whole
of society” response
and engagement, all of us work-
ing together to address violence in the home and inadequate community support systems.
Much of our Report is dedicated to considering what this insight means for the roles and responsibilities of individuals, organizations, and institutions,
including police services and particularly the RCMP. Flowing from this, we make
recommendations about how this collective
response can be fostered through a revitalized public safety system in which police services
remain important, but are
understood as being only part of a broader community safety ecosystem. The com-
munity safety ecosystem is a framework of governmental, institutional, and
agency and service provider
relationships, including processes
for community engagement.
Our main findings, lessons
learned, and recommendations are woven throughout the full Final Report and are also available
in a complete list in Part E of this Execu-
tive Summary.
LESSONS LEARNED MAIN FINDING
Recommendation
The Report is divided
into volumes, each focused on an area of our mandate.
volumes are divided into parts and chapters focused on specific topics.
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Report Volumes
![]()
Executive Summary and Recommendations
Volume 4
Community
Volume 7: Process
Appendices
Volume 1
Context and
Purpose
Volume 5
Policing
Annex A
Sample Documents
Volume 2
What Happened
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Volume 6 Implementation: A Shared Responsibility
to Act
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Annex B
Reports
Volume 3
Violence
![]()
Volume 7
Process
![]()
Annex C
Exhibit List
![]()
Turning the Tide Together: Consolidated Contents
![]()
Part A Commemoration
Part B The Mass Casualty
Part C The Mass Casualty Commission Part D The Final Report
– An Overview
Part E Main Findings, Lessons Learned, and
Recommendations Part F Next
Steps
![]()
introduction
Part A Commemoration
Part B The Ripple
Effect of the Mass Casualty
Chapter 1 The individuals
and Families Most Affected Chapter 2 The
Communities Most Affected
Chapter 3 The impact of the Mass Casualty
Part C Purpose and Approach
Chapter 4 Turning the Tide
Chapter 5 Commission Purpose and Process Chapter 6 Our Approach
Part D Nova Scotia’s
Public Safety System
Chapter 7 First
Responders in Our Communities Chapter 8 Other
Public Safety Partners
Chapter 9 Forging
a Public Safety
System Conclusion
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introduction to volume 2
Chapter 1 Events Before April 18, 2020
Chapter 2 Events on April 18, 2020 – Portapique Chapter 3 Events Overnight
Chapter 4 Events
on April 19, 2020 – 6:00 am to 10:15
am Chapter 5 Onslow Fire Hall
Shooting
Chapter 6 Events on
April 19, 2020 – 10:15 am to Noon Chapter 7 Events
from Noon on April 19, 2020, Onward
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introduction to volume 3
Part A The Perpetrator
introduction and Overview
Chapter 1 Perpetrator’s
History of violence and Coercion Chapter 2 Perpetrator’s
Financial History and Misdealings Chapter 3 Perpetrator’s Acquisition of Firearms
Chapter 4 Perpetrator’s Acquisition of the Replica RCMP Cruiser and Police Kit Chapter 5 interactions with Police and Other Authorities
Chapter 6 Missed intervention Points
Part B Mass Casualties
introduction
Chapter 7 The Study of Mass Casualty
incidents Chapter 8 Psychology
of Perpetrators
Chapter 9 Sociology of Mass Casualty
incidents
Part C Preventing
Mass Casualties
introduction
Chapter 10 Collective
and Systemic Failure to Protect Women Chapter 11 Keeping Women Unsafe
Chapter 12 it is
Time: A Collective Responsibility to Act
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introduction to volume 4
Part A Rurality
and Rural Communities
introduction
Chapter 1 Rurality and
Canadian Rural Communities Chapter 2 Crime in Rural Communities
Chapter 3 Rural Communities and Well-Being
Part B Community-Centred Critical Incident Responses
introduction
Chapter 4 Framework
for Community-Centred Responses Chapter 5 Public Warning Systems
Chapter 6 Meeting the Needs of Survivors and Affected Persons: Police-Based Services
Chapter 7 Meeting the Needs of Emergency Responders
Chapter 8 Meeting the Support Needs of Affected
Persons and Communities Chapter 9 “We Will Write Our Own Story”
Part C Community-Engaged Safety and Well-Being
introduction
Chapter 10 From
Community-Based Policing to Community Safety and Well-Being
Chapter 11 Facilitating
Community Engagement Chapter 12 Rethinking Roles
and Responsibilities
Part D Applying Lessons Learned: Access to Firearms and Community Safety
introduction
Chapter 13 Access to
Firearms and Community Safety Chapter 14 Police
Paraphernalia
Chapter 15 Cultivating Healthy Masculinities
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introduction to volume 5
Part A The Critical
Incident Response
introduction
Chapter 1 Five
Principles of Effective Critical incident Response Chapter 2 Critical
incident Command and Decision-Making
Chapter 3 information Management During the Critical
incident Response Chapter 4 Public Safety During Critical incidents
Part B The Continuing Crisis
Chapter 5 Post-Event Learning
Chapter 6 RCMP
Public Communications and internal Relations After the Mass Casualty
Chapter 7 issues Management and interagency Conflict in the Post-Crisis Period
Chapter 8 involvement of the Serious
incident Response Team in the Post-Crisis Period
Part C Reimagining Policing in Canada
Chapter 9 What Are the Police For? Chapter 10 A Future for the RCMP
Chapter 11 The Future of Policing
in Nova Scotia
Part D Everyday Policing Practices
introduction
Chapter 12 Police Discretion
Chapter 13 Five
Strategies for improving Everyday Policing Chapter
14 Everyday Policing, Equality and
Safety
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introduction to volume 6
Chapter 1 A
Purposive Architecture of Recommendations Chapter 2 Overcoming Barriers to Change
Chapter 3 Keystone: Fostering
Collaboration and Ensuring Accountability Chapter 4 Next Steps to Make Our
Communities Safer
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Chapter 1 introduction:
Purpose of the Process volume Chapter 2 Establishing
the Mass Casualty Commission Chapter
3 Designing the inquiry
Chapter 4 Our Work: Three Phases
Chapter 5 Recommendations Related to
Future Public inquiries Chapter 6 Expenditures
Chapter 7 Conclusion
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volume 1 begins with acknowledging and commemorating the lives taken
in the mass casualty and
recognizing the rippling effects of this incident on those indi- viduals, families,
and communities most affected. We do so by sharing
a selection of first-voice perspectives about immediate
and continuing effects.
This context – the harms caused by the perpetrator’s actions, the significant inadequacies in
responses to those actions, and the failures to take preventative measures long
before April 2020 – anchored the work of this inquiry.
in addition to
volume 1 setting out the context and purpose of the Commission’s work, it serves as an introduction to the Report. The volume contains four parts, beginning
with a commemoration of the lives taken. The second part describes the rippling
impact of the mass casualty. it follows the movement outward from the violent
centre of lives taken to introduce the individuals and families most affected,
and onward to the communities most affected. The third part of volume 1
outlines the Commission’s purpose
and approach. This volume concludes with a brief description of the public safety
system in Nova Scotia, discussing the public safety organizations that respond
to, assess, and take charge when critical incidents hap- pen in our
communities. We pay particular attention to some of the agencies that responded
to the mass casualty and its aftermath.
The mass casualty of April 18 and 19, 2020, created
profound grief, disruption, and destabilization in Nova Scotia and beyond. Early in our mandate, the Commission
adopted the image and metaphor of rippling water to signify the breadth and depth
of the impact of what happened over approximately a 13-hour period
on those two days and in their aftermath. The ripple acknowledges that
the imme- diate impact experienced by those most affected – the individuals, families, first responders, service
providers, and local communities – was appropriately the starting point of our mandate. it also captures the dynamic
impact of the mass casualty, which expanded outward and affected communities, institutions, and
society in Nova Scotia, across Canada, in the United States, and further afield.
We introduced the ripple image as we started our work, and we acknowledge that the rippling effects of
the mass casualty will continue after our Report is read and our
recommendations are implemented. No one can undo the perpetrator’s actions or the actions
taken by others in response:
these actions are the epicen- tre of concentric circles of
impact caused by one man. Collectively, individuals, communities, the province of Nova Scotia,
and all of Canada can learn from this
incident and work together toward enhanced safety and well-being in the future. An appreciation of the depth and breadth of this rippling
impact is an essential component of effective, concerted, forward-looking
efforts. Just as this impact has focused our work, so too it frames our Final
Report.
The Commission learned about the impact of the mass casualty in several ways, including through meetings with
family members, witness interviews, individual testimony with supporting documents
at public proceedings, two opening panel discussions, small group sessions
with directly and indirectly affected individuals, roundtables of people with
relevant expertise, and a consultative conference with indigenous people.
in addition, the Commission undertook a number of activities
to learn more from community members about this impact, including through
community conversations, consultations with stakeholders, and the Share Your
Experience survey (conducted to assist us in building our understanding of the
experiences of people in a range of different locations, contexts, and
settings, including those living in affected
communities and those working as emergency
responders). We provide an overview of what we learned about the impact of the mass casualty
in volume 1, but it is a central thread
woven into the whole Report.
More than a thousand
people generously provided
their insights into the impact of the mass casualty. This information has created a stronger awareness of the dimensions
of the rippling effect: it has expanded our understanding of the range of people who fit into the category
of those most affected; and it has enriched
our insight into the nature and size of the indirect effects of the circling
waves. it has reinforced the perception that, once initiated, a ripple has an immediate
effect and that it will not be diminished easily, with its vibrations
immeasurably reaching shores in all directions.
As noted above,
this volume begins with a commemoration of those whose lives were taken during
the April 2020 mass casualty. We asked all the families if they would like to
commemorate their loved ones in their own words. in Part A of vol- ume 1, we
set out the memories and the pictures they chose to share with us.
Part B provides
an introductory overview of what the Commission has learned about the impact of the mass casualty. it follows the ripple metaphor
movement outward from the violent centre of lives taken to introduce the
individuals and families most affected (Chapter 1) and onward to the
communities most affected (Chapter 2). Chapter
3 sets out a preliminary account of the impact of the mass casualty. We present what we learned
from three Commission activities: the opening
panel discussion on the human impact; the consultative conference with
indigenous people;
and the Share Your Experience survey. This summary
reflects input from those
directly and indirectly affected by the mass casualty.
More detailed
information about the effects of the mass casualty is contained throughout the
Report in specific aspects of the mass casualty response. For example, we
consider the ramifications of how public communications, next of kin notifications,
and support services provided to family member survivors and other community
members were carried out. One focal point of volume 4, Community, is the nature
of the repercussions experienced by emergency responders.
Part C of volume
1 describes the Commission’s work and introduces our Report. in Chapter 4, we introduce
our main findings,
the nature of the challenges ahead, and the need for concerted, collective action. We introduce a second impact
image to our framework to
complement the ripple image and mark a shift toward the future: turning the
tide together. This tide metaphor also signifies the transition from the
Commission to those charged with implementation: governmental institutions and
agencies, community-based organizations, communities, and individuals both in
their professional roles and as citizens.
in Chapter 5, we
describe the Commission’s purpose and approach. We set out and explain the
purpose of the Commission’s work, established by the mandate given to us by the governments of Canada and Nova Scotia,
and the processes we developed and carried out independently of governments and
other institutions to achieve this purpose.
in Chapter 6, we describe this
Report and the approach we took to reviewing, ana- lyzing, and understanding
all the evidence and information gathered and devel- oped by the Commission through
its three phases of work. First, we set out the
analytical framework used to shape this process. Second, we explain the
structure of the Report and how it is
organized. Third, we provide brief overviews of the con- tent of each of the
seven volumes.
Public safety is not just about people being safe but also their feeling safe. It is a
perception grounded in freedom from harm and the consequences of crime and
disorder in our homes, workplaces, and communities. It comes from the confi-
dence that government and public safety agencies will respond effectively to
emergencies, whether caused by acts of nature or human beings.
in Part D, we introduce the public
safety organizations that assess and respond when events happen in our communities. These institutions exist to safeguard
the
quality of life in our communities. We pay
particular attention to some of the agen- cies
that responded to the mass casualty and its aftermath.
We map out everyday
public safety, as well as during the response to the mass casualty, for three purposes.
First, this part introduces the agencies, their man-
dates, and the relationships among them to assist the reader in understanding
our findings about what happened leading up to, during, and after the April
2020 mass casualty. Second, it lays a foundation for understanding that the way the public safety system functions on a day-to-day basis is one factor that determines our collective ability to respond
to critical incidents
and other emergencies. Third, in this
discussion, we introduce the principle that we have a public safety system that is more than its constituent parts.
volume 2 sets
out the Commission’s main findings in the narrative of what hap- pened leading
up to, during, and in the aftermath of the mass casualty of April 18 and
19, 2020. As distressing as it is to recall
the violent attack
that ended the lives
of 22 people (one of whom was expecting a child) and injured others,
our mandate requires us to provide
a detailed account
of these events.
We have striven
to include enough detail to give readers
a clear, hour-by-hour account of the perpetrator’s actions as well as the response of community mem- bers
and those who had a formal duty to respond.
Formal responsibility rests with
first and secondary police responders, emergency services personnel (including
firefighters and paramedics), and other service
providers (for example,
tow truck operators
and medical examiners). Whenever possible, we include first-voice per- spectives
from those who experienced the mass casualty as witnesses, community members, service
providers, and as responders and overseers of the response. Witnesses and people around the perpetrator have only so much information, however, and analysis of evidence can take us only so far. Some of the perpetra-
tor’s actions – in particular, the motivation for his violent rampage – are
unknown at this time and likely will remain so forever.
volume 2 contains the Commission’s main findings in two key areas: in narrating
how the mass casualty unfolded
and in identifying any institutional and systemic
failures
discernable in the response, including any missed opportunities to prevent the mass casualty as a whole
or in some specific aspects.
identifying what went wrong and what additional steps could have been taken is critical to establishing
the lessons that may be learned from the mass casualty.
The Commission’s work is necessarily both backward-looking and forward-looking.
These findings
are a foundation for further and more refined findings in subsequent volumes
based on what the Commission has learned about why and how the mass casualty
happened. in these subsequent volumes, we elaborate on the lessons to be
learned by providing more information about the causes, context, and circum-
stance of the mass casualty. We draw a direct connection from the findings
set out in volume 2’s narrative account to the lessons to be learned and
our recom- mendations. it is our hope that this approach will help to ensure
that lessons are in fact learned and integrated into our systems for community
safety and well-being, including for those engaged in critical incident
response.
Chapter 1 examines the antecedents of the mass casualty – what happened
before April 18, 2020.
it focuses on information about
the perpetrator that contextualizes
the mass casualty. The first section presents an overview of the perpetrator’s
his- tory of violent behaviour, his illegal acquisition of firearms, and his
possession of police paraphernalia. The second section
sets out what the Commission learned about the perpetrator’s behaviour in the weeks leading
up to the mass casualty and, in particular, his reaction to the COviD-19 pandemic.
Chapter 2 provides a narrative account
of the evening of April
18. The first
section contains our findings
about the perpetrator’s assault on Lisa Banfield and the inju- ries she suffered. The second section
explains what happened
in Portapique after this assault. The details
are described from three points
of view: the perpetrator’s
actions, resulting in 13 fatalities in Portapique and in injuries to Andrew
MacDonald; the observations and actions of other community members, who in many
ways were the first responders; and the actions and observations of emergency
services personnel who came on scene. The Portapique
fatalities were Greg and Jamie Blair; Joy and Peter Bond; Corrie
Ellison; Dawn and Frank Gulenchyn; Lisa McCully; Jolene Oliver, Aaron Tuck, and Emily Tuck; and Joanne Thomas and John Zahl. The third
section steps away from the immediate situation in Portapique to the RCMP Operational Communications Centre and the non-commissioned officers who worked on
the response from further afield. it sets out and examines the RCMP’s approach to the critical
incident response in the first few hours of the mass casu- alty. The fourth section
reviews the decisions and actions of the RCMP executive
leadership, and the fifth section
looks at other agencies involved in the mass casu- alty and at communications
among agencies. The sixth section examines the issue of public communications, including
decisions about what information to share
with the public, and by what means,
during the first
two hours. The final section summarizes the Commission’s main
findings and conclusions about this period.
Chapter 3 provides a narrative account
of the period after midnight
and into the early
morning of April
19. it covers the perpetrator’s actions; RCMP decisions and actions; communications between the RCMP and other
agencies; actions taken by other agencies; and communications with the public
during this period. A final sec- tion summarizes the Commission’s main findings
and conclusions about the events overnight.
Chapter 4 sets out occurrences on
the morning of April 19 from 6:30 am to 10:15 am. it begins with Ms. Banfield
leaving her hiding place in the woods of Portapique to seek help at about 6:30 am. She had stayed
hidden overnight after
escaping from the perpetrator’s assault. The second section recounts
the perpetrator’s re-emergence
in Wentworth, thereby reactivating an active shooter situation over a larger geographical area than the
previous night. This narrative is ordered by the
locations where the perpetrator stopped, encountered other individuals, and killed an additional six people: Alanna Jenkins, Sean McLeod, and Tom Bagley on
Hunter Road in Wentworth; Lillian
Campbell on Highway
4 in Wentworth; and Kris- ten Beaton and Heather O’Brien on
Plains Road in Debert. He also terrorized Adam and Carole Fisher in Glenholme. Again the narrative is told from three points of view: the perpetrator’s actions;
community members’ observations and actions; and actions
taken by first-responding police and emergency
personnel. Sections that follow
continue the examination begun in Chapter
2: the work of the Oper-
ational Communications Centre and RCMP command decisions and actions; the role of the RCMP executive
leadership; actions taken by other agencies and inter- agency
communication; and the issue of public communications. The final section summarizes
our main findings and conclusions.
Chapter 5 examines the shooting at the Onslow
Belmont Fire Brigade
hall. The first section explains that the fire hall
had been set up as a comfort centre for indi- viduals and families evacuated
from Portapique. The second section describes an incident at 10:17 am when two
RCMP members, Cst. Terry Brown and Cst. Dave Melanson, shot at the emergency
management coordinator responsible for the comfort centre, Dave Westlake,
and RCMP officer
Cst. Dave Gagnon.
in the third section, we examine
the impact of this incident
from three perspectives. First,
we review the actions of Cst.
Brown and Cst. Melanson after they drew and dis- charged their firearms; the
actions of their supervisors once they were informed of the shooting; and other steps the RCMP took to address the shooting. Second, we describe the impact
this incident had on Mr. Westlake, Cst. Gagnon, and the
three individuals inside the fire hall during the shooting: Richard Ellison,
father of Corrie Ellison, one of the Portapique fatalities; Greg Muise, fire chief of the Onslow Belmont Fire Brigade; and his
deputy fire chief, Darrell Currie. Third, we examine the impact of the fire hall shooting on the Onslow community.
Chapter 6 returns to the account
of the perpetrator’s actions on the morning
of April 19 from 10:15 am until his death at 11:25 am. The first three
sections, like those in Chapter 4,
are organized around the perpetrator’s encounters with individuals at different
locations, resulting in three more lives taken and injury to another person: at the Shubenacadie cloverleaf, Highway 224, and before the perpetrator was killed at the Big
Stop gas station in Enfield. During the final 70 minutes of his life, the per- petrator shot and injured Cst. Chad
Morrison and killed Acting Cpl. Heidi Stevenson, Joey Webber, and Gina Goulet, before
being shot and killed by two RCMP members.
Each of these location-based sections begins with an overview of the
perpetrator’s actions, sets out community observations and actions, and ends
with the actions of emergency personnel. The remaining sections continue our
examination of RCMP command decisions and actions and the role of the
Operational Communications Centre, the decisions and actions of the RCMP
executive leadership, the decisions and actions taken by other agencies, interagency communications, and the issue of public
communications during this period. The final section
summarizes our main findings and conclusions.
Chapter 7 provides an overview of
the period following the perpetrator’s death on April 19, including both the immediate
aftermath of this critical incident
and the follow-up by the RCMP and other
agencies involved in the response
to the mass casualty. The first part examines
issues around crime scene management, with a focus on the
belated discovery of the fatalities at Cobequid Court in Portapique. The second section provides information
about forensic investigations and, more specifically, evidence
about items in the perpetrator’s vehicle at the time of his
death and a forensic analysis of the firearms he used during the incident. The
third section provides an account of how the RCMP and other agencies addressed
the needs of survivors and the families of the deceased for both information
and sup- port during this initial
period. We also discuss the impact of the RCMP’s
decision to charge Ms. Banfield with aiding in the supply of ammunition
to the perpetrator. The fourth section examines
the RCMP’s public communications following the
mass casualty. The final section
outlines steps taken
and the results
of internal and external
reviews of the response by various agencies to the events on April 18 and 19, 2020. This section includes
reviews undertaken by and of the RCMP and
by other agencies engaged in the response to the mass casualty. it also
provides an overview of investigations carried
out by the Nova Scotia Serious incident Response
Team into the Onslow Belmont Fire Brigade hall shooting and the death of the perpetrator.
volume 3 builds on the findings
we make in volume 2 about the perpetrator’s pat- tern of violent and intimidating behaviours and illegal acquisition of firearms. Over many years, this pattern
gave rise to numerous red flags and missed opportunities for prevention and
intervention.
Part A focuses
on the perpetrator. The perpetrator was raised in a violent home and became a violent man. The perpetrator
witnessed family violence, including intimate partner violence, at a young age.
He was abused by his father, who was abused by his own father (the
perpetrator’s grandfather), who was in turn abused by his father (the
perpetrator’s great-grandfather).
As an adult, the perpetrator’s violent,
intimidating, and coercive
behaviour extended ever outward:
to his intimate partners; to relatives, friends,
neighbours, and business associates; to his patients
and to vulnerable and marginalized peo- ple in the communities where he lived and worked; to
individuals in positions of power and control over him such as police officers
and colleagues participating in the review of his misconduct at the Denturist Licensing Board of Nova Scotia;
and finally to perpetrating a mass casualty. There are strong
connections among family violence, gender-based violence, and mass casualties,
but it is a complex relation- ship. Many people are directly
and indirectly affected
by the violent behaviour of
family members; fewer, though a significant portion of them, become violent themselves; relatively few go on to kill. Mass casualty incidents are rare compared
to these other kinds of harm, but the perpetrators of these attacks frequently have a history of gender-based, intimate partner, and family violence.
Chapter 1 of
volume 3 begins with an overview of findings about violence within the perpetrator’s family. The second
section examines his violent and coercive behaviour in intimate partner
relationships and toward others: women, denture patients, male acquaintances,
friends, and strangers, as well as his threats and threatening behaviour toward
police officers. Chapters 2 to 4 scrutinize how the perpetrator acquired the
means to carry out the mass casualty: his financial situ- ation and misdealings
(Chapter 2), his firearms and ammunition (Chapter 3), and the replica RCMP
cruiser and other police paraphernalia (Chapter 4). Chapter 5 provides an overview of what was known about the perpetrator’s violent behaviour,
firearms, and police paraphernalia, as well as what actions and interventions
were taken by individual members of the community, the Denturist Licensing
Board, and public authorities. it also includes our findings regarding the
perpetrator’s relation- ships with individual police officers.
The experiences
other people had with the perpetrator encompassed a range of behaviour, including emotional, psychological, and physical abuse
toward intimate partners and coercion and intimidation in those relationships. These accounts echo
Ms. Banfield’s experiences. The information provided also includes physical and
aggressive behaviour associated with alcohol consumption, sexual violence
toward low-income women and employees, sexually suggestive comments to patients
and employees, and physical violence toward men. Many people were intimidated
during encounters they had with the perpetrator.
in Chapter 6 of
volume 3, we examine how and why concerning behaviour – often called red flags or warning signs – was seen, yet interventions were either absent or
ineffective. We share what we have learned
about the dynamics
in these kinds of
situations that inhibit
affected individuals and other community members from taking action, as well as the patterns
in the responses of police
and other authori- ties. The perpetrator’s
privilege as a wealthy white man contributed to his impunity from adverse
official or social
consequences for his violence.
Part B of volume
3 provides an overview of what we have learned about mass casualties. it begins
in Chapter 7 by identifying a lack of common definition of these events and the
problems caused by this lack of clarity. We then examine trends in the rate and
nature of mass casualty incidents. The bottom line is that relatively little is
known about mass casualty incidents. This lack of knowledge is partially due to the rarity of these mass attacks. it is also a relatively new area of study, and progress has been hindered
by the lack of a shared definition of the term “mass casualty” and
limitations on the
collection of data.
We
extended our
knowledge base through an international scan of reports
on mass casualties, and Chapter
7 shares some of the comparative insights garnered through our review of reports
from the United Kingdom, the United States, Norway, Australia, and New Zealand.
in the conclusion to Chapter 7, we set out and discuss our recommenda-
tions for a single, inclusive definition of “mass
casualty incidents” and also set out
factors that should be integrated into data collection and future research and
pol- icy development.
in Chapter 8, we turn to the
question of whether mass casualties can be predicted. We conclude that a focus on preventing mass violence (by studying patterns
of behaviour and addressing root causes of such violence
through a public health
approach) is more promising than trying to predict it. Risk assessment tools are not useful
for predicting rare events such as mass casualties and can perpetuate biases
and stereotypes, so utility must be carefully considered. Also in Chapter
8, we examine the use of psychological autopsies by police. These
processes are a form of psychological
assessment used to evaluate the motivations of the perpe- trator of a homicide in circumstances
where the perpetrator has died. We consider the scientific value of these
tools, the concerns and best practices related to them, and evaluate the RCMP’s
psychological autopsy of the perpetrator against these standards.
Chapter 9 examines psychological and sociological insights
into the perpetrators of mass casualties. We
identify violence as a gendered phenomenon, interrogate the relationship
between traditional masculinity and mass violence, and review the clear connections between gender-based violence
and mass casualties. Studies show that mass casualties are committed almost
universally by men. The consis- tency in this gender variable across time and place warrants
close scrutiny. We review findings from recent sociological studies
that explore three interrelated
dimensions of this gendered phenomenon: the connections between mass casual-
ties and gender-based violence; traditional masculinity and masculinity
challenges; and the role of gun culture.
We find in Part B that the strong
connection between gender-based violence and mass casualties continues to be
overlooked in much research and commentary, as well as in measures
to prevent and respond to violence, including mass casualty
incidents. Gender-based, intimate partner, and family violence is dismissed as
“pri- vate” violence, but this violence harms us all. As Dr. JaneMaree Maher,
professor in the School of Sociology at Monash University in Melbourne,
Australia, explained in her testimony:
it impacts those around – both the victim and
the perpetrator. it impacts children. it impacts family members. it impacts
health services. it impacts workplaces. So there is
always a sense in which private violence is always already having public
effects that we are increasingly aware of.
Seeing
“private” and “public” violence as two distinct phenomena is incorrect and dangerous.
All too often, gender-based, intimate partner, and family violence
are precursors to the forms
of violence that are more readily seen as being of broader “public” concern. We
ignore these forms of violence at our collective peril.
While no person
or institution could have predicted the perpetrator’s specific actions on April
18 and 19, 2020, his pattern and escalation of violence could have and should
have been addressed. Many red flags about his violent and illegal behaviour
were known by a broad range of people and had been brought to the attention of police and others over a number of years. it was entirely predictable that he would continue
to harm people until effective
intervention interrupted his patterns of behaviour.
Mass casualties occur infrequently, but women, children,
and other marginal- ized people and communities
experience violence every day. Our perceptions of where the real danger lies
are misconceived, and we ignore the hard truth of the “everydayness” – the
commonness and seeming normalcy – of violence between intimate partners
and within families
and the ways in which this violence
spills out to affect other people too. Gender-based violence is also ubiquitous and under-reported in Canada. For far too
long, we have misperceived mass violence as our greatest threat without considering its relationship to other more perva-
sive forms of violence. We do so at the expense of public safety and community well-being.
The evidence shows clearly that
those who perpetrate mass casualties often have an unaddressed history of family violence, intimate partner violence, or gender- based
violence. Many mass casualties begin, as this one did, with an act of family
violence. The societal and cultural misapprehension that these forms of
violence are distinct from one another is mirrored in most institutional practices and priori- ties, notably in policing,
the media, and the delivery
of public services.
We conclude that strategies to prevent mass casualties must focus on ensuring the safety and well-being of all community members.
in Part C of volume 3, we build a
framework for preventing mass casualties with a focus on insights derived from
seeing mass casualties as an escalation of gender- based violence, including
intimate partner violence,
and from acknowledging their connection to family
violence. The pattern of escalation from gender-based violence to mass casualties is well established. it is alarming
to know that some
people responded to the early RCMP communications on the night of April 18,
2020, by thinking, “it’s a domestic situation.” The mistaken implication is that a “domestic situation” is not one that sets off warning bells.
And yet it should, not because every incident of gender-based or family violence
will result in mass
casualties, but because the first step in
prevention is in recognizing the danger of escalation inherent in all forms
of violence. As Commissioners, we believe this lesson to be the single most
important one to be learned from this mass casualty. Let us not look away again.
in drawing the overarching lessons to be learned, we delineate our collective fail- ures to protect women from gender-based violence in Chapter 10. in searching to explain these failures, we look at the state of our
knowledge about risk factors, barriers to reporting, the ineffectiveness of
many current interventions, and our growing knowledge about coercive control.
Our conclusion is that failures
to protect women, girls, and Two-Spirit, lesbian, gay, bisexual,
transgender, queer, intersex, and additional sexually
and gender diverse
(2SLGBTQi+) people from gender-based violence cannot be
attributed to a lack of knowledge.
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Gender-based violence
is an epidemic in Nova Scotia and in all of Canada,
as it is in most parts of the world. The United Nations
has been calling it a global pandemic
for years. violence
against women and girls is also endemic
in Canada and “in all societies.” Calling gender-based violence
endemic accentuates the ways in which
it has been consistently present
throughout societies to the point that it is seen by
many as routine or normal.
Within this context, we revisit Lisa Banfield’s experience and look at the ways she
was revictimized in the aftermath
of the mass casualty as an example
of some of the ways in which we fail to adequately address gender-based violence. We con- clude Chapter
10 with a brief summary
of evidence of the impact
of our collec- tive and systemic
failures. An active
and concerted whole
of society response
is required to counter this scourge.
in Chapter 11,
we look at the state of our knowledge about the ways in which we have failed to
prevent gender-based violence, thereby keeping women and girls unsafe. We focus
on understanding five areas where we collectively continue to founder: limited
understanding of risk factors and inappropriate and uneven use of risk assessments; overcoming
barriers to reporting; reliance on ineffective inter- ventions; misconceptions
and minimization of coercive control; and underfunding
and defunding of effective interventions. Our conclusion is that failures
to protect women from
gender-based violence cannot be attributed to a lack of knowledge. We recognize
the efforts of many individuals and organizations over decades – and that some
progress has been made in some areas. Yet gender-based, intimate partner, and family violence continue to prevail
with sweeping and wide-ranging consequences. We conclude that this prevalence
is the result of inadequate and uncoordinated action by individuals and organizations, coupled
with insufficient attention
to structural and institutional barriers that block progress.
in Chapter 12, we conclude volume
3 by recognizing that our Report comes at a critical
juncture for Nova Scotia and all of Canada, given the governmental com-
mitments in the Nova Scotia Standing Together
to Prevent Domestic
violence initiative and the National Action Plan to End Gender-Based violence. These ini- tiatives build on the many previous
reports and, in particular, the ongoing work to implement the recommendations made by the National inquiry
into Missing and Murdered indigenous Women and Girls. Our Report joins in this collective call to
action and underscores the ways in which the April 2020 mass casualty provides further reasons for us all to
take on this individual and shared responsibility.
Throughout volume 3 we offer
recommendations, based on our inquiry, for a path forward toward
preventing mass casualties through a fundamental reorientation of our collective responses to gender-based, intimate partner, and family vio- lence. in Chapter 12, we set out four lessons learned
through our work that can help
us to achieve that fundamental reorientation: mobilizing a whole of society
response; situating women’s experience at the centre; putting safety first; and
tak- ing accountability seriously. Putting safety first necessitates lifting
women and girls out of poverty, decentring the criminal justice
system, emphasizing primary prevention, and supporting healthy
masculinity.
Our mandate is
to inquire into the April 2020 mass casualty and the related causes, context,
and circumstances that surround it. The focus on one mass casualty incident is notable in light of both historical patterns of violence
and the ongoing reality of violence in the lives of many members of our
communities, both rural and urban. The disproportionate impact of this ongoing violence
on indigenous people and members of the African Nova Scotian communities has
been further com- pounded by law enforcement (both over- and underpolicing these communities)
and by a lack of culturally responsive and effective public services.
Throughout our work, as we learned
how the perpetrator targeted members
of marginalized
communities in Nova Scotia, we realized it provided but one example of the ways in which historical patterns of violence
are sustained and amplified.
We recognize this reality while at the same
time we acknowledge both the lim- itations and the gravity of the Commission’s
mandate. it is our sincere hope that lessons
learned and solutions recommended may assist
in addressing other
mani- festations of violence
within Canadian society.
We have attempted to pay attention
to this wider frame of reference in our work and, in particular, by being mindful
of the potential for unintended negative consequences of our
recommendations for members of marginalized communities. Our mandate requires
us to be concerned with the safety of all communities – and with all members of
these communities. We can meet this requirement only by paying
close attention to the needs
of the most marginalized and
by working with them to develop inclusive safety plans, supports, and strategies
to meet the needs of everyone concerned.
in volume 4, we
focus on the role of communities and their members in responding to critical
incidents and in contributing to community safety and well-being. Com- munities
and their members are affected by critical incident responses and by sys- tems for ensuring everyday
safety. They also have an active role in responding to incidents and in contributing to community safety
and well-being on an ongoing basis. The structure of our Report
recognizes that we need to rebalance the rela-
tionship between communities and police in ensuring public safety. To put it
simply, communities come first.
Our consideration of the theme of
community begins with a recognition of the rural dimensions of the April 2020
mass casualty. The mass casualty took place across Colchester, Cumberland, and
Hants counties, a relatively large geographic area of central Nova Scotia comprising rural areas and small towns. Portapique and Wentworth are small, isolated communities, for example, and the population den- sity is fewer than 15 people per square kilometre. This mass casualty
is the largest such incident to occur in a series of rural communities,
and this rural character is a contextual factor that helped to shape the incident itself and the response both during and after April
18 and 19. Rurality also contextualizes our understanding of
developments
before the mass casualty. The perpetrator moved between his cot- tage in
Portapique and his residence in Dartmouth, earning his income in denturist
clinics in Dartmouth and Halifax (with a significant rural client base) but
spending the greater part of each
week in Portapique.
Part A of volume 4 explores
the ways that life in rural communities is different from other environments. Although each rural community
is unique, there are some common features about rural ways of
living that coalesce into the idea of “rurality.” in Chapter 1, we examine the concept of rurality and rural life in Nova Scotia and, generally, in Canada. We also
address firearms ownership and use in rural commu- nities. Chapter
2 provides an overview of research and statistics about rural crime.
it also considers two current and related policing
challenges: lack of community
trust and confidence, and recent
developments in self-defence in the rural
context. in Chapter 3, we review Commission evidence about rural community well-being,
with a focus on Nova Scotia. As we move forward from the mass casualty,
it is essential that space is made for rural communities and rural voices in
conversa- tions and decisions on how best to ensure
community safety and well-being.
Part B of volume 4 introduces and
explores the concept of community-centred critical incident responses.
Community members play a part in everyday safety, and communities and their
members are active agents in all phases of critical inci- dent response. A central lesson
learned is that developing a community-centred
approach to critical incident response should be the focus moving forward. This
change requires putting communities at the centre and encompasses community- engaged processes
at all stages: prevention and mitigation, preparedness, response, and recovery. To fulfill these roles effectively, communities should be
involved in planning and preparations, and community members will require
education and training before a critical incident.
To protect lives and promote safety, communities and their
members will require warnings and other informa- tion during an incident.
Communities and their members also require information, supports, and resources after
an incident to assist them on their
path to restoring health and well-being,
including the re-establishment of a sense of safety. Sup- porting communities
and their members to full recovery assists in the prevention of and mitigation of long-term negative
outcomes that could contribute to future
critical incidents.
in Chapter
4, we consolidate what we have learned
about post-incident support into a framework for
community-centred responses to mass casualty incidents. The first
section of the chapter establishes the parameters for understanding
impact by exploring who is affected
by a mass casualty and what the impact is on health. The second section examines
three approaches to understanding post- incident needs and concludes with a brief
discussion of the impact of unmet needs. The third section proposes a set
of principles to guide community-centred critical incident responses, and the
fourth identifies several promising practices. The con- clusion draws together
these elements into a framework of guiding principles.
in Chapter 5, we examine the
development and implementation of effective pub- lic warning systems. We focus on evaluating whether
Alert Ready can provide
the robust public warning capabilities needed to ensure a community-centred response to mass casualty
incidents and other threats to public safety.
We begin by explaining key concepts and terms and providing a historical overview
of emergency alerting and the development and operation of the Alert
Ready sys- tem. We also
explore alternative approaches to public warning systems. We build on this
foundation by setting out what we have learned about community needs and experiences during
the April 2020 mass casualty, and more generally about the differential impact of alerting. On the basis of this
foundation of background information
and community perspectives, we assess Alert Ready and develop a set of public alerting system design principles to guide reform.
A concluding section contains our recommendations in
this area.
Chapter 5 focuses specifically on our findings
with respect to the need for a more
effective public warning system going forward. Deciding on the best system for public warning
is a decision for the Canadian public – a decision for communities.
The use of these systems by police agencies is a separate though equally
important issue, to which we turn in volume 5, Policing.
in the ensuing chapters of Part B,
we explain that public systems must be prepared to respond to mass casualty incidents
by having information and support systems in place to meet the needs of individuals, families, and communities affected by the incident. Communities and their
members also require
information, supports, and resources
after an incident to assist them on their path to restoring health and well-being,
including the re-establishment of a sense of safety. Supporting com- munities
and their members to full recovery assists in the prevention of ongoing (and mitigation of long-term) negative
outcomes that could
contribute to future critical incidents. We assess
approaches taken to meet the support needs of all those affected by the April
2020 mass casualty.
in Chapter 6, we probe how community-centred critical
incident responses can meet
the information needs of affected
persons during and after a mass casualty.
We build
on our findings about the information needs
of those most affected by the
April 2020 mass casualty and take a broader look at the victim services
approach employed by the RCMP. We examine proposals
to revitalize this approach and then
consider more transformative avenues tailored to the scale of these incidents.
We describe some promising practices in this regard. We conclude by setting out
the lessons learned, as informed by the framework of guiding principles
established in Chapter 4, and make a recommendation designed
to ensure the capacity to meet
the needs of survivors and affected persons following a mass casualty.
in Chapter 7, we use a similar structure to examine how best to meet the support
needs of emergency responders. We use the term “emergency responders” to mean all individuals who respond to an emergency, including fire, police,
and para- medics, as well as others, who by virtue
of their occupation or volunteer role,
are involved in responding to a critical incident either immediately or
in the hours, days, and weeks after a critical incident. The list includes
everyone from the communica- tions operator who takes a 911 call to emergency
room nurses, to those who volun- teer in recovery efforts, and those who
process and restore crime scenes, including professional cleaners and tow truck operators. Another term for this group is “pub-
lic safety personnel,” but emergency responders is more reflective of their role as it connects
to our mandate. As we noted in volume 1, Purpose and Context, we esti- mate that 500 to 600 people
were involved in their work capacity in the response to the April 2020 mass casualty
and its aftermath.
Chapter 7 is divided
into three parts.
The first part examines approaches to under- standing the needs of emergency responders following a mass casualty incident. This examination considers
impact and steps that can be taken to facilitate healthy help-seeking
behaviours. The second part explores prevention and proactive plan- ning for
wellness. We conclude this second part with our main findings, lessons learned,
and a recommendation focusing on ensuring planning and preparedness for community-centred approaches to critical
incident responses that integrate a wellness-focused preventative approach. The third part reviews the steps taken to meet the needs of emergency responders following the April 2020 mass casualty.
We then take an in-depth look at the experiences and perspectives of emergency
responders in accessing support services to meet these needs. The concluding
part draws together these experiences with a focus on proposals made by emergency
responders about what steps could
be taken to improve the support provided
to this group in the future.
in Chapter 8, we
examine how best to meet the support needs of affected persons and communities.
The support needs of affected persons and communities can be met both through
the formal channels
established by public
sector institutions, such as
healthcare delivery systems, and more informally through community- based and
individual, personal channels. We focus here on formal mechanisms for providing
support through healthcare systems and victim services. This chapter begins
with an examination of approaches to understanding the support needs of affected
persons and communities following mass casualty incidents. it
summa- rizes the information explored in Chapter
1 and builds through
discussions about categories
of needs, types of support services, and community needs. The second section
sets out in detail the approaches taken by Nova Scotia Health Authority and
Nova Scotia victim Services, a program of the Department of Justice, to devel- oping
and implementing support systems and services following the April 2020 mass
casualty. The third section details the experiences and perspectives with these
services. The final section contains our conclusions, main findings, lessons
learned, and recommendations.
in Chapter 9, we
consider community-based responses to the April 2020 mass casualty. We heard from many community
members of Colchester, Cumberland, and Hants counties that they do not want to be
defined by the April 2020 mass casualty, and we heard about the steps they were
taking to move forward and foster resilience. At the same time, there is extensive
concern about the breadth
and depth of unmet need for support
within the most affected communities. We conclude there has been a “healing deficit” that amounts to
a public health emer- gency, and we make recommendations for urgent action to promote
recovery and support resilience.
in Part C of volume 4, we consider how to
establish safety ecosystems that actively engage community members in the
promotion of safety and well-being of every individual
and the community as a whole. in Chapter 10, we outline the Canadian experience
with community policing and examine obstacles to implementing new models of
policing that result in unfulfilled promise. We conclude that rather than starting with questions about the role of
policing, we need to recalibrate the ques- tion and start with community. We
pose two questions: What makes communities safe?
What makes rural communities safe? Our response is that system-wide plan- ning for community safety and well-being
holds the greatest potential to achieve these objectives.
in Chapter 11, we recommend that
federal, provincial, and territorial governments enact frameworks for community
safety and well-being and resource them through long-term sustainable funding.
These frameworks provide the structure, but it is community engagement that
will be their animating force. it is commu- nity members and their
organizations across Canada who will determine what is required to meet their needs for community safety and
well-being. The focus should be on creating the right conditions for change, not on coming
up with the right program or strategy.
in the first section of Chapter 11, we set out what we have learned about the
steps required to create the conditions and structure for substantive community
engagement: committing to equality, establishing planning frameworks, and lead-
ing guided processes for the generation of a shared vision of community safety
and well-being. in the second section, we identify mechanisms to build the infra-
structure required to facilitate the implementation of plans for community safety and well-being, including through
continued community engagement. These mechanisms are ongoing
collaboration, multi-sectoral approaches, and evaluation.
What will change in our society
if we begin from the starting point
that we are all
responsible for keeping each other safe? in Chapter 12, we examine what this col- lective responsibility approach means for some of the actors and entities
that do not have a formal role
within the safety ecosystem: individuals, businesses, and the media. One of our focal points
here is developing a stronger culture
of bystander intervention. We
also consider the role and responsibilities of professionals who deliver public
services to individuals who are marginalized by their low-income status and through other
oppressive processes including systemic racism. This focus flows from our earlier findings
about the perpetrator’s pattern of predatory, violent, and intimidating behaviour
toward members of the African
Nova Scotian community in Dartmouth and the North
End of Halifax (in volume
3, violence, Part A).
Our analysis extends
more generally to government oversight
of public service provision by independent professionals to members of marginalized communi- ties. We pay particular attention
to reassessing these roles and responsibilities as they relate to the April
2020 mass casualty. This reassessment also serves as an example of the type of recalibration that will enable an effective
whole of society response.
Our mandate
directs us to inquire into the perpetrator’s access to firearms and police
paraphernalia as aspects of the causes, context, and circumstances of the April 2020 mass casualty.
in Part D of volume 4, we examine what steps should
be taken to apply
the lessons learned through the Commission’s work to the systems we have in place to regulate and enforce access
to firearms and police
paraphernalia.
One of our core findings is that the enforcement of Canada’s firearms regime was inadequate to prevent
the perpetrator from acquiring the means to carry out the
April 2020 mass casualty. in Chapter 13, we evaluate this regime on the basis
of how it operates in conjunction with other aspects of our public and
community safety systems. it is Canadian society, our community of communities,
that decides on which lethal
weapons should be available for civilian use, for which
purposes, and under which conditions.
in the first section,
we provide a snapshot of the firearms situation in Canada designed to provide
background information and context for the discussions that follow.
it consists of an overview
of the regulation of firearms
and a range of statistical data about guns and their
use. The second
section is a summary of our
findings on the perpetrator’s access to and use of firearms and an
identification of the issues that arise from these findings.
The third
section sets out what we have learned
about mass casualties, firearms, and firearms control.
We explore the relationship between
guns, gun control,
and mass shootings in the United States and briefly review American
responses to these events. We analyze the firearms-related responses to mass casualties in New Zealand, the United Kingdom,
and Australia and draw lessons
to be learned from these
international experiences. The fourth section surveys Canadian firearms
regulation, beginning with a historical perspective and moving
to developments after the April 2020 mass casualty.
Here we focus on the way technological devel-
opments, mass casualties, and other crimes
have shaped Canada’s
approach to gun control.
in the fifth section of Chapter
13, we move to a forward-looking perspective on violence prevention
through gun control. The discussion is structured around three main strategies: legislative and regulatory reform, addressing cross-border smug- gling of firearms,
and strengthening regulatory enforcement. The sixth section
examines the other side of the prevention equation, looking beyond regulation to issues such as public
awareness and education
and the mechanisms to promote community
safety. The chapter ends with our conclusions and recommendations.
“Police paraphernalia” is the term
adopted by the Commission for police vehicles, uniforms, and equipment, whether
or not genuine. Police equipment includes
varied items: firearms
and other less lethal weapons;
equipment associated with police vehicles such as “silent patrol”
partitions and light
bars; and police
identifi- cation badges. it also includes highly sensitive and secure
items such as encrypted police radios, police-issued laptops, and police
notebooks.
in Chapter 14, we examine the
effects of police impersonation on public trust. We heard very clearly in our
community consultations and public proceedings that the police impersonation
aspect of the April 2020 mass casualty had a ripple effect on public trust
in the police, and particularly the RCMP. We review the broader pol- icy issues involved in the
regulation of police paraphernalia, including systems to manage the inventory and disposal of these items, and the
challenges involved in regulating access to many specific
items of police
paraphernalia. We conclude
that measures to address these issues must be systemic and
comprehensive.
in Chapter 15,
we explore approaches to cultivating healthier masculinities. This discussion builds
on our findings and recommendation in volume 3 with respect to the role of unhealthy
conceptions of masculinity in the perpetration of violence. We conclude that
initiatives in support of cultivating healthy masculinities will con- tribute
to one of the main cultural shifts required to end gender-based violence, and,
moreover, that they are an important strand in a whole of society response.
in the first section,
we summarize information gathered by the Commission about a
public health approach
to preventing male violence. in the second
section, we explore
initiatives to cultivate healthy masculinities in relation to four main pre-
ventive public health
strategies identified in volume 3: prevention, early
interven- tion, response, and recovery and healing. Chapter
15 is a case study of one set of initiatives that communities should
consider for inclusion in their safety and well- ness plans.
in volume 5, we
build on the findings and conclusions reached elsewhere in this Report by turning to the institutional context of policing.
This volume contains
four parts. in Part A, we evaluate the quality of the RCMP’s critical incident
response on April 18 and 19, 2020. Part B documents
the continuing crisis that afflicted
the RCMP in the days, weeks, and months
after the mass casualty. in Part C, we build a
framework for
improving community safety by making police agencies more dem- ocratically accountable, more attentive to evidence about
good practice, and bet-
ter oriented to articulating and serving the common good rather than particular
interests. Part D of volume 5 considers the everyday practices of policing that con- tribute to the overall
effectiveness and legitimacy of the police.
Complex critical
incidents are characterized by uncertainty and by their singularity. The
individuals who were professionally involved in the critical incident response
were placed in that position because they were assigned to work in H Division
on the day when the perpetrator set out to murder and cause mayhem.
in these circumstances, mistakes
and misjudgments on the part of responders and super- visors
may be inevitable. We recognize that these individuals did their
best in unprecedented circumstances and that, ultimately, it is the perpetrator
who is responsible for his actions. Nonetheless, in order to evaluate the quality of the crit- ical incident response, it is necessary to look carefully
at the decisions and actions taken and not taken by some
individuals, particularly those who occupied supervi- sory and leadership
roles.
Our evaluation,
first, of the decisions made at key points in the critical incident response
and, second, of the RCMP’s overall preparedness and processes for crit- ical
incident response, is offered in the service of learning the lessons that may
be drawn from the mass casualty in order to help keep communities safer in the
future. At every step where it was possible for us to do so, we have chosen to
learn and not to blame. Our mandate directs
us to choose learning, and in Part A of volume 5, with that objective, we share details
about the critical incident response that offer lessons for future preparation
and response.
in Chapter 1, we
set out five principles of effective critical incident response that emerge
clearly from the extensive research and policy literature we reviewed. These principles are the importance of
critical incident preparedness in the quality
of a critical incident response; the uniqueness of every critical
incident and the conditions of uncertainty under which decision-makers must act; the necessity of cultivating a culture of
interoperability, in which organizations and personnel consistently work respectfully and collaboratively; the importance of recog-
nizing the role played by community members during a critical incident and of
communicating effectively with community members; and the value of grasping the opportunity to learn from a critical
incident response in order to respond
more effectively in the future.
These principles guide our discussion of the crit- ical incident response on April 18 and 19, 2020, and of the RCMP’s institutional
preparedness for
effective critical incident response. Also in Chapter
1, we intro- duce the 2014 report prepared by Ret’d. A/Commr. Alphonse MacNeil
after a mass casualty incident in Moncton, New Brunswick, in which three RCMP members were killed and two more were
injured. We explain the significance of the MacNeil Report to our work and also identify some limitations to that report.
in Chapter 2, we evaluate the
RCMP’s policies and preparedness for a large-scale critical incident
response in rural Nova Scotia in April 2020. in particular, we con-
sider the extent to which
the RCMP had absorbed and implemented the lessons
learned and recommendations from the 2014 Moncton mass casualty incident and
from the MacNeil Report. We find that some good work was done in the immediate
aftermath of the Moncton incident, but that work was not institutionally
sustained and did not produce
lasting improvements in preparedness and supervisor training.
Chapter 2 also addresses
the quality of the RCMP’s critical incident
decision- making during the April 2020 critical incident response. We
analyze the origins and effect of particular problems
identified in the main findings
in volume 2, What
Happened: uncertainties about command structure; a lack of training for
front-line supervisors; the time taken for a trained critical incident commander to take com- mand; the failure to make contingency plans for alternative scenarios; and short- comings within the command
decision-making at various phases of the critical incident response. Throughout
this chapter, we document the impact on the over- all effectiveness of the
RCMP’s critical incident response of prioritizing reactive pursuit of the perpetrator over seeking to coordinate the response to ensure that other important tasks, such as seeking
out and attending to other possible
victims and witnesses, were also completed.
Chapter 3
evaluates the RCMP’s processes for finding and managing information and
explains how the clear and consistent account of the perpetrator’s replica RCMP
cruiser that was provided by community members was lost to the critical
incident response. in particular, we identify shortcomings in the RCMP’s
training, processes, and procedures for managing information during a critical
incident response. We share the evidence we heard about best practices for
emergency communications centres and information management during a critical
incident response, and make recommendations for future practice. Also in Chapter 3, we discuss four additional areas that
presented particular challenges to the critical incident response of April
2020: tracking RCMP member locations; the RCMP’s use of mapping technologies; police radio protocols; and the
availability of air support.
The RCMP was not the only organization that played a role in the critical
incident response of April 18 and 19, 2020. Other police and emergency
service agencies were also
directly involved in the critical incident response. in Chapter 3 of vol- ume 5, we share what we learned about how best to cultivate
the culture of trust
and mutual understanding that is essential to interoperability. We make recom- mendations
to ensure that future critical incident responses are better coordinated across
all responding agencies.
The evidence we received in our
process demonstrates that lives can turn on ensur- ing accurate and timely
public communications during a mass casualty. Accord- ingly, in Chapter
4, we evaluate the institutional processes and decision-making that led to the RCMP’s failure to issue effective public warnings in April 2020. We
emphasize that the RCMP was aware of the importance of public communi- cations in critical incident
response well before April 2020. The RCMP’s failure to have adequate processes and training in
place in H Division in April 2020 must be understood against
this backdrop. in particular, we consider the history of insti-
tutional decision-making that led to a situation in which the command group was
unaware of the potential to use Alert Ready to broadcast a public warning about a mass casualty. This chapter also identifies and challenges the persistent opera- tion of myths about how community
members will respond to public warnings. We emphasize the police responsibility
to issue public communications about how an incident may affect people and the steps they can take to keep themselves safe. it
is unreasonable to expect community
members to figure these things out for themselves.
Part B of volume 5 documents the continuing crisis
that afflicted the RCMP in the
days, weeks, and months after
the mass casualty. in Chapter 5, we consider
the efforts made – and those not pursued – to learn from the critical
incident response. More than two years after
the event, RCMP leadership had done very little to sys-
tematically evaluate its critical incident
response to the deadliest mass shooting
in Canada’s history. We discuss
the significance of the RCMP’s
failure to conduct an operational debriefing with those who responded to the April 2020 mass casu-
alty, and evaluate the evidence we heard about the fate of efforts made by some
RCMP personnel to obtain an after-action review
of the critical incident response. Returning to the five principles of effective critical
incident response, we empha-
size that the lessons learned from a critical incident response are not
specific to the responding agencies
or to where the incident
took place. The public is owed
not only the exercise of a review
but the sharing
of lessons learned
with the broader community to help keep us all safer. Waiting
months or years
to conduct
an after-action review serves no
one. indeed, had the RCMP conducted and pub- lished a comprehensive after-action review, some of this Commission’s findings and recommendations would likely have been addressed by
the organization well before the publication of this Final Report.
in Chapter 6, we turn to the
RCMP’s public communications and internal relations after the mass casualty. We
set out the policies and procedures that relate to pub- lic communications and
identify a history of reviews and inquiries making adverse findings about and
recommendations for change to the RCMP’s approach to pub- lic communications.
We document evidence that the RCMP provided inaccurate information to the public after the April 2020 mass casualty.
We then discuss concerns that
arose inside and outside the RCMP about its public communications, as well as concerns
within the RCMP about internal
briefing practices and a lack of
support provided to H Division
to assist with public and internal communica- tions after the mass casualty.
These concerns set the context for an April 28, 2020, meeting between Commr. Brenda Lucki, members of national
headquarters, and senior members of H Division.
We describe the circumstances that led to this meeting and evaluate what happened during
the meeting. in the final sections of this chapter, we discuss the continuing
ramifications of the April 28 meeting for the relationship between H Division
and national headquarters, and the persistence of internal conflict within the
RCMP over public communications in the months after the mass casualty.
in Chapter 7, we turn to issues management and inter-agency conflict
after the mass casualty.
This chapter explains
the genesis and role of the issues manage-
ment team established in H Division, including a disagreement with the Province of Nova Scotia about how this
team should be funded. We evaluate the RCMP’s
approach to two issues that attracted great public interest in the
months after the mass casualty: the risks and benefits of using the Alert Ready system for polic-
ing, and the 2011 Criminal
intelligence Service of Nova Scotia
bulletin about the perpetrator. in particular, we consider inter-agency conflict that arose
between H Division and municipal police leaders in Nova Scotia about how these issues should be publicly addressed.
in Chapter 8, we
turn to the work performed by the Nova Scotia Serious inci- dent Response Team
(SiRT) after the mass casualty and the work performed by the RCMP with respect
to the SiRT’s investigations. The SiRT investigated two incidents involving
RCMP members arising from the April 2020 critical incident response: the Onslow
fire hall shooting, and the killing of the perpetrator. in July
2020,
the RCMP referred evidence it had received about another Nova Scotia police service to the SiRT, and the SiRT declined
to investigate this information.
We
explain the SiRT’s jurisdiction in relation to the RCMP and describe its public
reporting responsibilities. We explain communications between the SiRT
and the RCMP. We then turn to the RCMP’s
July 2020 referral
and the SiRT’s
handling of this referral.
Public trust in the police is integral to the police’s
capacity to do their work effec-
tively. Public trust is, in turn, affected
by public conversations about how well the
police do their work, and by how police agencies respond to those public conver-
sations. The April
2020 mass casualty, and more particularly the RCMP’s response to public concern about its response to the mass casualty,
created significant public mistrust
in the RCMP. However, for many community members, particularly
those who have a history of being overpoliced and underprotected by police,
trust in the police was already low. Conversations about the RCMP’s work in the April 2020 critical
incident response played out against
a broader conversation about the role and limits of the police
in fostering and safeguarding community safety. in Parts C and D of volume 5, we turn to the role of
the police within an inclusive vision of community safety.
in Part C, we address fundamental questions about the role and structure of police agencies in Canada. in Chapter 9, we consider the question, What are the police
for? We suggest
that establishing clear
answers is a precondition to dem-
ocratic deliberation about the functions the police serve and how they do their
work. We adopt, and recommend that Canadian police
agencies and governments adopt, eight principles of policing that address the role of police in a democratic and inclusive society. Chapter
9 also explains how the lessons learned (and not learned) by police and government agencies from past reports about policing,
and the efforts made (and not made) to implement and sustain this learning,
have shaped our work and recommendations.
in Chapter 10, we propose a future for the RCMP. First, we take stock of what we
learned about the current state of the RCMP’s management culture and opera- tional
effectiveness, particularly in its contract policing service. We recommend
statutory amendments to the RCMP Act to
clarify the relationship between the RCMP commissioner and the responsible minister, and also to strengthen the role of the RCMP Management Advisory Board and the Civilian Review and Com- plaints
Commission. in each case, these amendments will also promote the public transparency and democratic accountability of these bodies. We then turn to the
RCMP’s relations
with its contract partners. A recurring theme of reviews of the RCMP is the
challenge of ensuring that the RCMP’s provision of contract policing services
is responsive and accountable to the communities it serves. We conclude that
the RCMP’s tendency not to include contracting partners in its strategic
decision-making, documented in past reports, persists, and that the RCMP has
failed to adopt a strategic or coordinated approach to contract policing
policies and core policing functions.
We then turn to
the important topic of rural policing. The RCMP’s career model undervalues
rural general duty policing, regarding that work as the first step in a career
ladder that will bring members to other policing functions and locations. This approach
creates a disconnect between RCMP members
and the communities they serve, and it fails to recognize
and foster the distinctive skillset
that is required for effective rural policing. We identify that maintaining the unique responsibilities of police under the rule
of law necessitates that adequate policing services be pro- vided in rural and remote communities.
Throughout this
Final Report, we emphasize that effective police agencies are learning
institutions: capable of recognizing and responding to the changing expectations of the communities of which they are part, and capable of learning
from their past actions in order to do better in the future. in the next
section of Chapter 10, we explain how police recruitment, education, and research
contribute to the effectiveness of police services, and we evaluate the RCMP’s approach to these functions.
The last section of Chapter 10
discusses the RCMP’s management culture. By man- agement, we refer to commissioned officers,
which in the RCMP means those
sworn members who hold the rank of inspector, superintendent, chief superin-
tendent, assistant commissioner, deputy commissioner, and commissioner. We also include civilian employees who
hold equivalent ranks or leadership positions.
We are particularly focused on management culture
because, if the RCMP is to
make the significant changes we call for in this Report, the work of leading
these changes and engaging members in
them will be led by commissioned officers and their civilian equivalents. indeed,
if the RCMP’s management does not share a com- mitment to making these changes – or worse, if some members of management
actively work to undermine efforts to reform the RCMP – these efforts will likely fail.
in Chapter
11, we turn to the future of policing in Nova Scotia.
We provide a brief
history of policing in Nova Scotia and a description of the present structure
of policing services in the province. This chapter also describes some of the key
reforms that have been made to the
police in Nova Scotia since colonization. We then set out six recommendations for changes that should promptly
be made to Nova Scotia policing.
These changes can and should be implemented while broader conversations about community safety are
unfolding. We call for a struc- tured
community-wide process to discuss and decide the future structure of polic- ing
services in Nova Scotia.
Part D of volume
5 considers the everyday practices of policing that contribute to the overall
effectiveness and legitimacy of the police.
in Chapter 12, we explain
that low-visibility decision-making is a defining feature of police work
and a particular characteristic of the work performed by front-line police
officers. The discretion exercised daily by police officers in their
interactions with community members is best understood as a permission that is
extended by society to individual police officers to use “their considered
judgment in certain ways in certain situations.” Legal and constitutional principles, including Charter rights and freedoms, set lim-
its to police discretion. Nonetheless, most exercises of police discretion will
never come to any form of official attention or review. At the same time, these
decisions have a significant impact on what crime and social problems come to
broader offi- cial attention and how effectively social problems are countered.
They also affect community trust in the police.
The police power to shape the official record
by the manner in which front-line officers exercise discretion is not merely a theoretical concern. in our process, we heard
about police failures
to hear and respond effectively to community mem- bers
who expressed fear of the perpetrator or sought to report his violence. These accounts were echoed in other incidents
that were well known to, and widely discussed among, community members
and experts who contributed to our work. Two other examples from rural Nova
Scotia arose repeatedly in these conversa- tions: the RCMP response
to complaints made in 2017 by Colchester County res- ident
Susan (Susie) Butlin about her neighbour Ernie Duggan before Mr. Duggan killed
Ms. Butlin; and the RCMP’s treatment in 2007–8 of Digby County resident Nicole
Doucet (also known as Nicole Ryan), who was subjected to violence includ- ing coercive
control by her husband, Michael Ryan. We introduce these examples
in Chapter 12 and return to them throughout Part D of this volume, along
with other evidence we heard about how police exercise their discretion when
gender-based and intimate partner
violence are reported.
The problems that we document throughout this Report are long-standing and far from simple. However,
in Chapter 13, we suggest that everyday
policing practices
can be improved by implementing a coordinated set of fundamental strategies, each of which is designed to improve how front-line
police exercise their decision- making authority in low-visibility situations. These five strategies address the selection
of police students and police recruits, police education, note taking and
record keeping, front-line supervision and feedback,
and community-engaged policing.
Chapter 14 of this volume builds on
recommendations made in volumes 3, vio- lence, and 4, Community, to consider
the relationship between everyday practices of
policing, equality, and securing community
safety. We identify
the need to shift
police officers’ understanding of their role to acknowledge the primacy of secur-
ing the safety of those who experience violence. We also identify the central role played by misogyny within the police
failings that are documented throughout this Report. These problems are not limited
to the RCMP: they are also present
in other Canadian police services. indeed,
as we documented in volumes
3 and 4, misogyny is not by
any means limited to policing. Nonetheless, the operation of misogyny within
policing is particularly harmful to women’s equality, and therefore to all of
us, and can undermine achievements in law reform and efforts to modernize
policy. in Chapter 14, we suggest that countering misogyny, racism, homophobia,
and other attitudes that undermine universal human dignity must be placed at the centre of everyday
policing practices across Canada.
Our mandate
required us to conclude our work as Commissioners by submitting findings,
lessons learned, and recommendations. Rather than the end of a process,
however, we encourage you to think of this Report as a beginning or, even
better, as a continuation of the effort many people have already made to strengthen com- munity safety and well-being, including by advocating
collectively for the inquiry. Recommendations alone cannot bring about change
unless they are adopted, championed, and acted on.
implementation has been an important consideration for us throughout our work. We have made it a priority
to hear perspectives and insights
related to implemen- tation from many people
– including many of those
who lead or who are part of institutions and groups that will need to drive
important changes. volume
6 draws on what we learned
about implementation and is motivated by the urgent need to ensure that action
is taken and that positive changes in our communities can – and will – happen.
Chapter 1 explores the interconnected nature of the recommendations in the
Report and makes the case for why they must be implemented on a comprehen- sive basis
and with a whole of society approach. in this chapter,
we explain the purposive architecture of our recommendations built of three components. Two components, foundational ideas and a
scaffolding that will guide the construction of a new approach
to community safety,
together illustrate the unity of purpose
and strategic directions that underlie the many proposals for cohesive
community- engaged safety ecosystems. Recommendations directed to effective critical incident response are a third component
– the storm wall that will protect
the structure in difficult times.
Chapter 2
acknowledges that the path to change has many potential barriers and sets out strategies to overcome these obstacles. These strategies draw on what we have heard and learned from many
practitioners and experts over the course of
our work, as well as on what we have learned through the environmental scan of prior recommendations and the
international scan compiled by the Commission (available in Annex B: Reports).
We hope that these general lessons learned about how to effectively implement
reports of public inquiries, task forces, and reviews
will provide guidance and assistance with implementing this Report.
in Chapter 3, we share our recommendation for a broadly
representative imple-
mentation and Mutual Accountability Body that should be appointed by the fed- eral and Nova Scotian governments to ensure that the recommendations drive ongoing focus and action. in keeping with our architectural metaphor, this body is the keystone: the last building
piece, the one on which other structural elements can depend for support.
A keystone is considered essential to maintaining opti- mum function of a structure.
Finally, in
Chapter 4, we share steps and actions that those most affected, com- munity
members, community organizations, advocacy groups, policy specialists,
researchers, the media,
and the public
can take to maintain the momentum behind implementation. We believe these
steps and actions will grow in depth and impact
when people come together with intent to make change
happen. The examples
we provide are not exhaustive, and individuals and groups will have
their own ideas about how to make changes that are best for their communities.
volume 7
describes the various processes involved in leading and designing the Mass Casualty
Commission. This volume provides a comprehensive record of the steps
we took and the reasons
behind them. Understanding how we carried
out our mandate provides a backdrop to the findings, lessons learned,
and recom- mendations detailed in the other volumes. Our added purpose in
setting out those steps and decisions
in detail here is to provide assistance to
future inquiries.
There are seven
chapters in this volume. Chapters 1 and 2 provide general infor- mation about
the nature and role of public inquiries. As Commissioners, we were bound to the
directions provided to us in the Orders in Council by both Canada and Nova Scotia (Appendix A). Those Orders
required us to conduct a comprehen- sive public inquiry
to determine what happened and to make recommendations
to avoid such incidents in the future. They required us to consider a wide
range of causes, context, and circumstances beyond the immediate ones that were
most directly of interest to the families of those whose lives were taken.
Although we grounded our work each and every day in the memory of those whose
lives were taken and diligently sought to answer the questions the families had
about their loved ones, we were required to conduct a public inquiry as
directed by the Orders in Council.
Chapter 2, “Establishing the Mass Casualty
Commission,” explains the genesis of the Commission and the mandate
it received from the governments of Canada and Nova
Scotia that defined
its parameters. Both the public pressure that led to the
Commission’s establishment and its mandate
“to be guided by restorative prin- ciples in order
to do no further harm”
are important contextual factors underlying
our work. These principles were to guide the process
but did not limit or shape its purpose (in getting to the truth of what happened) nor its goal (to make recom-
mendations for the future). While restorative principles guided our work, they were not
an end in themselves.
in Chapter 3, “Designing the inquiry,” we discuss the logistics of getting the Com-
mission off the ground. We share how we benefited
from early consultation with individuals who have expertise working
on public inquiries, along with where
we chose to establish our offices and our approach to hiring staff. We
also introduce the individuals and groups who engaged in the Commission’s process as Partici- pants, and we explain what that
role entails. We then provide information about rules we developed
in consultation with Participants to guide our process, and how
we supported participation and public engagement throughout our mandate. We explain how we implemented communications through dedicated efforts
to engage the public,
including how we worked with the media, in that public engage- ment. We also consider the impact
of the COviD-19 pandemic on the inquiry and offer some thoughts on the interim
Report.
Chapter 4, “Our Work: Three Phases,”
introduces the framework
we developed to guide our
public proceedings and how we put our design into action. in the “Phase 1:
Building the Core Evidentiary Foundation” section of this chapter, we detail our approach to establishing the
facts of what happened on April 18 and 19, 2020, as well as our Phase 1 public
proceedings.
“Phase 2: Examining Causes,
Context, and Circumstances” explains the steps
we took to better understand the facts we had established in Phase 1. it
introduces the themes and issues that guided us as the Commission sought to
understand how and why the mass casualty occurred, including our three
foundational pil- lars – Policing, Community, and violence
– and how they shaped
our Phase 2 public
proceedings.
in “Phase 3: Shaping
and Sharing,” we describe our process of consulting with those most directly affected, with
communities, and with stakeholders. The con- sultations offered an opportunity
for us to hear about proposed recommendations from diverse voices and
perspectives. This process was crucial in enabling us to develop practical and
meaningful recommendations that could be championed and implemented by members
of the public, policy-makers, public institutions, community groups, and others
at the conclusion of the Commission’s mandate.
in Chapter 5, we
make some recommendations to assist in the set-up phase of future public
inquiries and to ensure that they have the necessary tools to fulfill their mandates.
in Chapter 6, we provide
information about the Commission’s expenditures.
in Chapter 7,
“Conclusion,” we reflect on our process and make a forward-looking invitation
to you, our reader, to take up the Commission’s recommendations and be part of
the work ahead to secure our community and collective safety and well-being. in this way, we can all
contribute to preventing future harms, we can learn from the lessons
of the mass casualty, and we can put in place better
ways to respond.
The conclusion
is followed by our acknowledgements of those who contributed to this work.
The
appendices include, among other documents, our Rules of Practice and Pro- cedure, our decisions, and a detailed
calendar of our public proceedings. We have also prepared
three additional annexes. “Annex A: Sample Documents” contains
samples and guiding documents we prepared in the course of our work.
These annexed documents provide further insight into our processes that we hope
will assist future inquiries. “Annex B: Reports”
contains reports commissioned by us as well
as reports prepared
by our team. in addition
to providing a wealth of knowl-
edge and analysis within our commissioned reports, this Annex includes import- ant
documents such as the environmental scan of 71 past Canadian reports and a
record of what we learned through the Share Your Experience survey and commu- nity conversations. “Annex C: Exhibit
List” contains the full list of materials marked as exhibits by the Commission.
Part E: Main Findings, Lessons
Learned, and Recommendations
We frame our conclusions in three steps. First, we identify findings
that pertain to the questions
and issues laid out in our mandate. From these main findings we identify
lessons learned, which reflect the knowledge we have gained. From these lessons
learned, we build our recommendations so that people across our govern- ments,
institutions, and communities can begin to take action
right away.
Our findings, lessons learned, and
recommendations are woven throughout the Report and we encourage you to review
them in that context too. They are also included here as a complete list to aid
understanding and implementation.
Chapter 1 Events
Before April 18, 2020
MAIN FINDING Over
many years, the perpetrator’s pattern of violent and intimi- dating behaviours and illegal acquisition of firearms gave rise to numerous red flags
and missed opportunities for prevention and intervention.
MAIN FINDING
in the six weeks before the mass casualty,
the perpetrator further isolated his common law spouse from her family as his
behaviour became erratic and increasingly concerning to her.
Chapter 2 Events
on April 18, 2020 – Portapique
MAIN FINDING The
mass casualty began with the perpetrator’s violent assault of his common law
spouse, Lisa Banfield.
MAIN FINDING
Community members were an essential part
of the initial response to the mass casualty. Their central role was not adequately acknowledged, and the indispensable
information they could provide was not factored into the RCMP’s response.
MAIN FINDING First-responding members
acted appropriately when they
established an immediate Action Rapid Deployment (iARD) response and entered Portapique and when they established an
initial containment point at the intersec- tion
of Portapique Beach Road and Highway 2. These members acted with great courage
in an extremely dangerous environment.
MAIN FINDING
The RCMP’s failure
to assign a scene commander
created gaps in the initial
critical incident response. These gaps meant that aspects of the response
were not well coordinated and that important tasks, such as identifying
eyewitnesses and flagging
the need to conduct interviews, were not prioritized and therefore not conducted in a timely
manner, and in some cases
not at all.
MAIN FINDING
Key information conveyed
by 911 callers from Portapique was not accurately or fully captured within the RCMP incident
activity logs, nor was it fully conveyed to first responders and the RCMP command group.
MAIN FINDING The critical
incident package call-out
process was cumbersome, requiring many individual
phone calls to supervisors and specialist resources.
MAIN FINDING
RCMP policy did not clearly assign
supervisory roles and respon- sibilities for the period before a critical
incident commander assumes command of the critical incident
response. Uncertainty about these roles and responsibilities was evident from an early stage within the RCMP’s response in
Portapique.
MAIN FINDING When it became apparent
that Sgt. Andrew
(Andy) O’Brien could not attend the scene to assume the
role of scene commander, the district command group should have appointed an alternative scene commander.
MAIN FINDING The RCMP command group
wrongly concluded that Portapique community members were mistaken when they
reported seeing the perpetrator driving a fully marked RCMP cruiser. They were too quick to embrace an explanation
that discounted the clear and consistent information that several eyewitnesses had provided independently of one another.
MAIN FINDING
RCMP supervisors did not direct basic
investigative steps during the initial critical incident response in
Portapique, nor did they assign responding members to capture information that
would facilitate investigation. important community sources of information were ignored, with significant consequences for the critical incident response.
MAIN FINDING RCMP
members did not have a good understanding of the geography of Portapique, and many had never been there before April 18, 2020. The
RCMP did not seek out local knowledge
about back roads, and information that was shared by a member
who was on scene was overlooked.
MAIN FINDING
District command efforts to review
containment were hampered by computer difficulties in the Bible Hill
detachment. Not all RCMP supervisors were trained in the mapping technology to
which the RCMP subscribes.
MAIN FINDING
During
the initial critical
incident response, and in the absence of a
scene commander or an on-duty district supervisor, RM Rehill was overtasked.
MAIN FINDING
The RCMP did not make effective systematic efforts to alert Por-
tapique residents to the threat presented by the perpetrator or to look for potential injured victims. The initial
immediate Action Rapid Deployment (iARD) responders
focused on finding
the perpetrator, and this focus was appropriate for that group. However, the overall command
decision-making did not adequately consider how best to protect and, if
necessary, to rescue Portapique residents.
MAIN FINDING
The RCMP’s lack of preparation and contingency planning for air
support to be provided during a critical incident when maintenance is being conducted
created a distraction for Operational Communications Centre (OCC) employees
and command. The search for an alternative helicopter diverted these personnel
from other important tasks.
MAIN FINDING
The RCMP public communications during the evening of April 18,
2020, seriously understated the threat presented by the perpetrator and the
associated risks to the public.
Chapter 3 Events Overnight
MAIN FINDING
There was an unacceptable delay in the
assumption of command by a fully trained and briefed critical incident
commander.
MAIN FINDING The
RCMP critical incident
command structure lacked
a dedicated information analyst.
MAIN FINDING
The RCMP critical
incident command did not adequately consider a wide range of scenarios, including worst-case
scenarios, and failed to develop contingency plans based on the most severe
possible outcomes.
MAIN FINDING
The RCMP’s failure to act on the clear and repeated information
about the perpetrator’s replica RCMP cruiser continued overnight on April 19, 2020.
MAIN FINDING The
RCMP critical incident
command failed to review containment when they had the opportunity to do so. This failure
meant that gaps in the contain-
ment, which had arisen in the absence of a scene commander, were not addressed.
MAIN FINDING The RCMP critical
incident command did not develop and opera- tionalize a general evacuation plan, nor did it take into account
possible survivors of the violence.
MAIN FINDING The RCMP critical
incident response was hindered by system-wide poor communication and failures
of coordination.
MAIN FINDING The RCMP did not provide
further public communications about the mass casualty
overnight and in the early morning of April 19, 2020. Community residents took active steps to
share information about the mass casualty and to seek to ensure the safety of
themselves and others.
Chapter 4 Events on April 19, 2020 – 6:00 am to 10:15 am
MAIN FINDING
The RCMP did not treat Lisa Banfield as a surviving victim of the
mass casualty; that is, as an important witness who required
careful debriefing and who would need support services.
MAIN FINDING The RCMP did not provide
advice to community members about what precautions they should take to ensure
their safety. in the absence of this information, community members adopted
a range of strategies to stay safe, some
of which may have put them at greater risk.
MAIN FINDING Poor
navigation technology and a lack of local geographic knowledge by responding RCMP members slowed the RCMP response to informa-
tion received about the perpetrator’s location.
MAIN FINDING The RCMP’s failure to
publicly share accurate and timely infor- mation, including information about
the perpetrator’s replica RCMP cruiser and disguise, deprived community members
of the opportunity to evaluate
risks to their safety and to take measures to
better protect themselves.
MAIN FINDING
Essential workers, including victorian
Order of Nurses (vON) employees, were
particularly at risk because of the nature of their work. The RCMP did not share accurate and timely information, including information about the perpetrator’s replica RCMP
cruiser and disguise, with these workers or their employers. By not sharing
this information, they deprived these essential workers
and their employers
of the opportunity to evaluate
risks to the safety of the workers. This opportunity would have
allowed them to take measures to better protect themselves.
MAIN FINDING
The command post did not take sufficient
steps to reassess the strategic and tactical
response, even after it began to consider
the possibility that the perpetrator had escaped
Portapique.
MAIN FINDING The
briefing of RCMP members was inadequate throughout the critical incident
response and particularly during the shift change on the morning
of April 19, 2020.
MAIN FINDING
The RCMP did not have a clear alternative to calling 911 for the public to report concerns
about family and loved ones, or to provide information that may have been significant
but did not relate directly to the perpetrator’s whereabouts.
MAIN FINDING The RCMP’s critical
incident response did not deploy resources according to a coherent
and coordinated strategy. its approach was reactive.
MAIN FINDING The
RCMP directive to the Nova Scotia Medical
Examiner Service not to release information about cause, manner,
and circumstances of death to family
members was unnecessary and harmful in the circumstances of this investi- gation, and it compounded the
grief and mistrust of some family members.
MAIN FINDING
The RCMP’s H Division and national executive leadership had not predefined or practised their
roles and responsibilities during a major
critical
incident response. As a result,
their role was unclear. Opportunities for the executive leadership to support the critical incident
response were overlooked.
MAIN FINDING The
command group did not share information about the unfolding mass casualty with senior executive
leadership in H Division or national
headquarters in a timely, coordinated, or accurate way.
MAIN FINDING The
lack of shared RCMP, Emergency Health Services (EHS), and firefighter protocols
to ensure that non-police emergency
responders are safe and
able to perform their work created an uneven response
in which these
responders were at times exposed to greater safety risks and at other
times may have been prevented from doing work that would have aided the critical incident
response or subsequent investigation.
MAIN FINDING The RCMP did not systematically share information with other
emergency responders, including volunteer fire services and Emergency Health Services,
that would have permitted these responders to evaluate risks to their safety and take measures to better protect themselves.
MAIN FINDING
Media
has an important role to play in a critical
incident response. The RCMP’s
approach of sharing information primarily via social media was insufficient to strategically engage local media outlets. The media was insufficiently
utilized as a partner in public communications on April 18 and 19, 2020.
Chapter 5 Onslow Fire Hall Shooting
MAIN FINDING
The command post and Operational Communications Centre
did not take adequate measures to ensure that all members were aware of the
location of the comfort centre and that a marked RCMP cruiser was stationed at
this location. This information should have been broadcast repeatedly by radio
or otherwise shared with all responding members, and it should have been
acknowl- edged as received.
MAIN FINDING
The Onslow Belmont
Fire Brigade hall should have been a place
of safety for community members, including those who were directly affected by
the mass casualty. Fortunately, the Onslow fire hall shooting did not cause
death or physical injuries,
but this incident
turned a place of safety into a site of further
harm.
MAIN FINDING The
procedure that must be followed by police after a use of potentially lethal
force should not be varied during a critical incident response unless there is
an immediate threat from a physically present perpetrator. This exception did not apply
in the circumstances of the Onslow fire hall shooting.
MAIN FINDING
The RCMP command group did not recognize the gravity of the Onslow
fire hall shooting. They failed to take the necessary steps to evaluate the circumstances
of the shooting, secure the scene, or evaluate the involved members’ capacity
to continue with the critical incident response.
MAIN FINDING
in the weeks and months after the
incident, the RCMP continued to underestimate the gravity of the Onslow fire
hall shooting. They did not take sufficient steps to hear community concerns,
nor recognize that those who were placed at risk during the shooting required
support. These failures caused lasting harm to the RCMP’s relationships with the Onslow community and the people at the fire hall that day.
Chapter 6 Events on April 19, 2020 – 10:15 am to Noon
MAIN FINDING
Overall, the RCMP did not adopt a strategic, coordinated approach to the positioning of members while
searching for the perpetrator on April
19, 2020. However,
individual supervisors and risk managers
tried to coordi- nate member positions in response to the information available to them.
MAIN FINDING
The critical incident response was
hindered by the inability to scale up resources in a timely
fashion. The steps
taken to seek additional resources were ad hoc and diverted the attention of the command
post and risk managers.
MAIN FINDING
Handing coordination of general duty
members to the risk manager created additional difficulties in coordination
between the command post and general duty members, and it further overburdened
the risk managers and Operational Communications Centre.
MAIN FINDING inadequate public
communications constrained the flow of information and assistance from the
public to the critical incident response.
MAIN FINDING Despite
receiving information that some residents of Portapique were unaccounted for, the RCMP did not conduct a timely search for additional living or deceased victims.
MAIN FINDING
in the absence of coordinated victim
support arrangements, and with no organized notification process for confirmed
deaths, concerned family members called 911 to both seek and provide
information. These calls added to the Operational Communications Centre’s
workload at a very busy time in the critical incident response.
MAIN FINDING
The critical incident response was
hindered by a lack of coor- dination, communication, and interoperability between the RCMP and the Truro Police Service.
MAIN FINDING
Alert Ready was the best available tool
to warn the Nova Scotia public about the mass casualty and to provide updates
as the information available to the RCMP changed.
MAIN FINDING The
critical incident response was hindered by the failure to coordinate with key
emergency management services including the Divisional Emergency Operations
Centre and the provincial Emergency Management Office.
Chapter 7 Events
from Noon on April 19, 2020, Onward
MAIN FINDING
The RCMP’s failure to find the fatalities at Cobequid Court in a timely
manner resulted from inadequate RCMP scene management and an empha- sis on
pursuing the perpetrator at the expense of other police responsibilities.
A systematic door-to-door search was not conducted until 19
hours after the first 911 call from
the Portapique community. This is an unacceptable delay.
MAIN FINDING
These
problems were exacerbated by the RCMP’s
failures to act on
information shared by family members
and lack of communication with concerned
family members and community residents. in some instances, it took far too long for
the RCMP to make next of kin notifications or provide updates to family members
who were anxiously seeking information about the well-being of their loved
ones.
MAIN FINDING
The RCMP did not find all forensic evidence at crime scenes. in some instances,
evidence was found by family members and the public (and,
eventually, by Commission investigators) after crime scenes had
been released.
MAIN FINDING
The services offered by the RCMP and
Nova Scotia victim Services did not fully meet the needs of those families and
communities most affected by the mass casualty. in the absence of a coordinated
and planned approach, ad hoc attempts to scale up services were insufficient.
MAIN FINDING The RCMP’s next of kin
notification policy and guidelines are inadequate. These notifications were not carried
out in a coordinated and timely
manner. RCMP members were not adequately trained
to carry out these duties
with skill and sensitivity.
MAIN FINDING
The RCMP did not provide adequate information services to those most affected because
of systemic gaps in policy,
the inadequate allocation of personnel, and the lack of provision of training for personnel charged
with providing these services.
MAIN FINDING
After
the mass casualty, the RCMP prioritized institutional and
investigative imperatives over the needs
of survivors and family members.
The RCMP’s information-sharing practices with survivors and family members were
inadequate.
MAIN FINDING
Nova Scotia victim Services did not
fully meet the need for support
services after the mass casualty. Gaps arose from the lack of proactive service
provision and from limited navigation assistance. Support services were not
adapted to address the needs and circumstances of those most affected, including the distinct needs of those who lived in Portapique. People
residing outside of Nova
Scotia faced additional hurdles to accessing provincially funded support
services.
MAIN FINDING After
the mass casualty, the RCMP public communications strat- egy did not provide
timely and accurate information about the mass casualty and the
ensuing investigation.
MAIN FINDING
The RCMP did not undertake an after-action review
of its response to the mass casualty.
Introduction and Overview
MAIN FINDING
There was intergenerational violence in
the perpetrator’s family. The perpetrator was physically and emotionally abused as a child and, as an adult,
he was violent toward his father and uncle Glynn.
MAIN FINDING
As an adult, the perpetrator developed
an alcohol use disorder and was known to become violent when he drank to excess.
Chapter 1 Perpetrator’s History
of Violence and
Coercion
MAIN FINDING The
perpetrator’s pattern of violent and intimidating behaviour was facilitated by the power and privilege
he experienced as a white man with professional status and substantial
means.
Chapter 2 Perpetrator’s Financial History and Misdealings
MAIN FINDING The
Commission cannot conclude
on the available evidence that the perpetrator was a paid police
informant.
MAIN FINDING The
Commission cannot conclude
on the available evidence that the
perpetrator was involved
in the purchase or sale of drugs,
in money laundering, or in organized crime.
MAIN FINDING The
perpetrator had a history of financial misdealings that included manipulative
and predatory patterns of behaviour.
Chapter 3 Perpetrator’s Acquisition of Firearms
MAIN FINDING incomplete
information sharing between the Canada Border Services Agency (CBSA) and other
law enforcement agencies, including Criminal intelligence Service Nova Scotia,
meant CBSA was not able to fully assess risk fac- tors when the perpetrator applied for a NExUS card or when he crossed
the border. The
information-sharing infrastructure at that time left the CBSA with incomplete
knowledge about the perpetrator.
MAIN FINDING
in this context of incomplete
information available to the CBSA, the risk factors that were known to the CBSA
(including that the perpetrator was possibly
undervaluing motorcycle parts, and that he crossed
the border frequently) were not assessed holistically
with other indicators of concern that were known to other agencies but not the
CBSA.
MAIN FINDING
The perpetrator’s illegal
acquisition of firearms
provided him with the means to
carry out the mass casualty. Despite many red flags, existing enforcement practices were ineffective in preventing the perpetrator from illegally
acquiring and possessing these firearms
and from smuggling
them across the land
border between the United States
and Canada.
Chapter 4 Perpetrator’s Acquisition of the Replica
RCMP Cruiser and Police Kit
MAIN FINDING GCSurplus and RCMP asset management policy were inadequate for ensuring that sensitive
material such as decals were fully removed from decommissioned RCMP vehicles
and destroyed. These inadequacies facilitated the perpetrator’s access
to the means to fabricate the replica RCMP cruiser.
MAIN FINDING
GCSurplus training and oversight of its
warehouse employees were inadequate, particularly with respect
to what steps should be taken to identify
and report suspicious activity.
MAIN FINDING The
perpetrator’s acquisition of decommissioned police cars and police uniform and
kit, and particularly his fabrication of a replica RCMP cruiser, provided him
with additional means to carry out the mass casualty. Ownership of many of these elements
is unregulated, although
it was unlawful to possess
some of the items he acquired.
MAIN FINDING Many community
residents knew about the perpetrator’s replica RCMP cruiser, but no one reported its existence to
authorities.
Chapter 5 Interactions with Police and Other Authorities
MAIN FINDING The
perpetrator’s violence and illegal firearms came to the attention of police on repeated occasions in the years
prior to the mass casualty. Due to a number of structural
and systemic problems, these serious allegations regarding a single individual did not prompt an appropriate police response. These structural problems are: implicit
bias in police decision-making, failure to identify and address gender-based
violence, the lack of effective investigation by the police forces, the lack of
detailed notes by RCMP members and ineffective supervision, the short period of
record retention, the siloing of information between agencies, whether due to different database systems or failure to share information, and lack of effective communication between the HRP, the Truro Police,
and the RCMP.
Chapter 6 Missed Intervention Points
MAIN FINDING Despite
widespread community knowledge of the perpetrator’s violent and otherwise illegal,
intimidating, and predatory behaviour over a number
of years, there were impediments to safely reporting concerns, including a fear
of retaliation, ineffective access points, and a lack of faith in an adequate police
response. These impediments were magnified by
the operation of power and privilege, and by a lack of trust and confidence in police and other authorities, particularly for members of
marginalized communities. The barriers to reporting resulted in missed red
flags and opportunities to intercede in his behaviour.
LESSON LEARNED A
cultural shift is required so that (a) our institutions accom- modate
accessible, safe, and credible reporting mechanisms; (b) promoting crime
prevention and community safety becomes a shared responsibility; and (c)
existing systemic biases favouring
privileged perpetrators are addressed.
Chapter 7 The Study of Mass Casualty
Incidents
LESSON LEARNED A clear
data-collection, research, and policy strategy
is necessary to build our understanding of mass casualty
incidents. This strategy
must be centred on widespread acceptance of a common definition to
facilitate tracking and research. The definition must address existing gender
bias and permit research and policy
exploration of the links between mass casualty incidents and gender- based violence, intimate partner violence,
and family violence.
FRAMEWORK FOR TRACKING MASS CASUALTY INCIDENTS
The Commission
recommends that
(a)
All individuals and entities engaged
in data-collection research
and policy development,
including law enforcement agencies and other authorities, adopt this definition
of a mass casualty incident:
An intentional act of violence during which one or more
perpetrator(s) physically injure(s) and/or kill(s) four or more victims,
whether or not known to the perpetrator, during
a discrete period
of time.
(b)
All individuals and entities engaged
in data-collection research
and policy development,
including law enforcement agencies and other authorities, collect data on the
following:
(i) information about the perpetrator, including but not limited to:
•
whether the
perpetrator had a history of violence, including coercive control, sexual
assault, uttering threats, and criminal harassment (stalking); whether those
behaviours were reported or not; whether charges
were laid or not; outcome
of criminal charges;
•
whether the perpetrator had a history
of hate-based crimes
or expressing hateful sentiments toward an identified group; whether
reported or not; whether charges
were laid or not; outcome
of charges;
•
whether the
perpetrator had a history of extremism or connection to extremist movements or
online forums;
•
whether the
perpetrator had a history of suicide attempts or suicidal ideation;
•
whether the perpetrator had a history
of harming or killing pets or animals, or threatening to do so;
•
whether the
perpetrator had a history of deliberately causing damage to property;
•
whether the
perpetrator had a history of being subjected to or witnessing family violence;
•
whether the perpetrator had a history
of alcohol and/or
substance dependence;
• whether and how the perpetrator explained the mass casualty;
•
whether the perpetrator had a manifesto and the contents
thereof; and
• the connection, if any, between the perpetrator and the victims.
(ii)
information about
access to weapons
and ammunition, including but not limited to:
• specific weapons/firearms used;
•
how the
weapons/firearms were acquired; whether lawfully or unlawfully acquired and
kept;
•
the amount
of ammunition the perpetrator had access to or had stockpiled;
• how ammunition was acquired; and
•
history of
weapons-related charges or complaints; whether criminal charges were laid or
not; outcome of charges.
(iii)
information about the trajectory of the incident, including but
not limited to:
•
the pathway
to the incident, including whether
the perpetrator shared information about the plans
and if so by what means and with
whom (“leakage”); whether
this information was reported or otherwise came to authorities’
attention; whether such reports were acted on and if so, how;
•
the location
of the mass casualty, including
whether the attack began in one place and moved to
another or others;
•
the perpetrator’s
relationship with the place where the mass casualty incident happened;
• the duration
of the active phase of the mass casualty incident;
and
• the means by which the mass casualty incident
ended.
Chapter 8 Psychology of Perpetrators
MAIN FINDING
The focus of efforts to prevent mass
casualties should be on studying patterns of behaviour and addressing the root causes of mass violence
rather than seeking to predict the risk presented by specific individuals.
LESSON LEARNED
Community safety can be improved through
community-wide public health approaches. Such approaches include
(1) intervening to support and redirect those at risk of
perpetrating mass violence; and (2) addressing the root causes of violence.
A PUBLIC HEALTH APPROACH TO
PREVENTING MASS CASUALTY INCIDENTS
The Commission
recommends that
Strategies for prevention of mass casualty incidents should
adopt public health approaches that are complex, nuanced, and community-wide while also
addressing the perspectives, experience, and needs of marginalized communities.
LESSON LEARNED
Forensic psychological autopsies and
other forms of forensic psychological assessment are useful to the extent that they adhere to best practices.
Canadian behavioural sciences
units and forensic
psychologists must be aware of and
attend to the operation of bias, stereotypes, and victim blaming
in this field.
EXTERNAL
EVALUATION OF RCMP BEHAVIOURAL SCIENCES BRANCH
The Commission recommends that
(a)
The RCMP commission
an expert external evaluation of the Behavioural Sciences Branch to assess the extent to which its policies,
procedures, personnel, and work product:
(i)
reflect the best practices set out in volume 3, Chapter 8 of
this Final Report;
and
(ii)
are attentive
to, and effectively counter, the potential operation
of bias, stereotypes, and victim blaming.
(b)
The external
evaluation should also make recommendations as to how the Behavioural Sciences
Branch can improve its policies, procedures, practices, and training to implement best practices; identify
and counter the operation of
stereotypes and victim blaming; and ensure that the
failings documented in this Final Report are not replicated in
the future work of the Branch.
(i)
This evaluation, and the steps
taken by the RCMP to respond to the
evaluation, should be published on the RCMP’s website.
(ii)
Other law enforcement
agencies should review the completed evaluation and implement both the lessons
learned and the best practices into the behavioural sciences
aspect of their mandates.
PERIODIC REVIEW OF RCMP BEHAVIOURAL
SCIENCES BRANCH
The Commission
recommends that
(a)
The RCMP periodically obtain
an expert external
evaluation of the Behavioural Sciences Branch’s work to
ensure that this work:
(i)
reflects the best practices set out in volume 3, Chapter 8, of this Final Report;
and
(ii)
is attentive to, and effectively counters, the potential operation of bias,
stereotypes, and victim blaming.
(b)
These evaluations, and the steps taken by the RCMP to respond
to them, should be published
on the RCMP’s website.
CONFLICT
OF
INTEREST IN FORENSIC PSYCHOLOGICAL ASSESSMENT
The Commission
recommends that
Where a forensic psychological assessment has the potential to
shed light on the death of a police
officer or may affect evaluations of the quality
of a police agency’s work, that assessment should be completed by an
independent forensic psychologist or unit. in this context, independence means
that the psychologist or unit has no historical or present employment or
reporting relationship with the police agency concerned, and that measures to
prevent bias are put in place.
Chapter 9 Sociology of Mass Casualty Incidents
MAIN FINDING While violence is overwhelmingly perpetrated by men, most men
do not perpetrate violence. However, mass casualties are a gendered phenomenon.
Mass casualty incidents are committed almost universally by men. By whatever measure we use, most serious violence in
North America is committed by men and boys.
This includes violence against strangers, violence against family members and intimate
partners, and mass casualties. Gun ownership, gun-related fatalities, and gun
violence more generally are all gendered phenomena.
MAIN FINDING
As a result
of gender bias,
the strong connection between gender-
based violence and mass casualties continues to be overlooked in much research and commentary, and in measures to prevent and respond to violence, including
to mass casualty incidents.
Chapter 10 Collective and Systemic Failure
to Protect Women
MAIN FINDING Gender-based,
intimate partner, and family violence is an epi- demic. Like the COviD-19
pandemic, it is a public health emergency that warrants a meaningful,
whole of society response.
MAIN FINDING Although
experienced by all genders, these forms of violence affect a disproportionately large number of women and girls. The impact is even
more severe on some communities of women and girls marginalized within Cana- dian society:
indigenous women and girls; Black
and racialized women
and girls; immigrant and
refugee women and girls; Two-Spirit, lesbian, gay, bisexual, trans- gender, queer, intersex, and additional sexually
and gender diverse
(2SLGBTQi+) people; people with disabilities; and women living in
northern, rural, and remote communities.
MAIN FINDING Economic marginalization and criminalization heighten
the risk of violence
against women and girls.
MAIN FINDING The COviD-19 pandemic
has intensified rates of gender-based violence
worldwide.
MAIN FINDING The RCMP’s treatment of Lisa Banfield
during the RCMP’s
H-Strong investigation is an example
of the kind of revictimization that makes it less
likely that women survivors of gender-based violence will seek help from police.
The victim blaming and hyper-responsibilization (holding of an
individual to higher standards than what would typically be expected of the
average person) to which Ms. Banfield was subjected by community members
reflect myths about “triggers” in a mass casualty
and that a woman is responsible for her partner’s actions. This reaction also has
a chilling effect on other survivors of gender-based violence.
LESSON LEARNED
Active
steps need to be taken by police and Crown counsel
to ensure fair treatment of women survivors and to end inadvertently discouraging women from reporting
gender-based violence.
INTIMATE PARTNER VIOLENCE AND POLICE AND
PROSECUTORIAL DISCRETION TO LAY CRIMINAL CHARGES
The Commission
recommends that
(a)
Police and Crown
attorneys / counsel carefully consider the context of intimate partner
violence, and particularly coercive control, when criminal
charges are being contemplated against survivors of such violence; and
(b)
Police investigations
and public prosecutions should engage subject matter experts to help ensure that the dynamics of intimate partner
violence are understood.
LESSON LEARNED Active steps must be taken to counter myths and stereotypes about “triggers” in mass casualties and victim blaming
and hyper-responsibilization of women
survivors of gender-based violence.
COUNTERING VICTIM BLAMING AND HYPER-
RESPONSIBILIZATION OF
WOMEN SURVIVORS
The Commission
recommends that
Federal, provincial, and territorial governments work with and support
community-based groups and experts in the gender-based advocacy and support
sector to develop
and deliver prevention materials and social
awareness programs that counter victim blaming and hyper-responsibilization
(holding of an individual to higher standards than what would
typically
be expected of the average
person) of women
survivors of gender-based violence.
Chapter 11 Keeping Women
Unsafe
MAIN FINDING Police use of risk assessment tools
in situations of intimate partner violence is inadequate and,
moreover, they are applied unevenly by different police forces across
Canada.
MAIN FINDING The
gender-based violence advocacy and support sector is working to deepen our contextualized
understanding of risk factors through a variety of initiatives, including
domestic homicide reviews,
action research projects that include interviews and
collaborations with survivors, research into specific issues such as the role
of pets and livestock ownership in risk assessments, and development of risk assessment tools that can be used by women themselves and by organizations that serve them.
LESSONS LEARNED
Our understanding of risk factors for intimate partner violence
has grown but must be continually deepened and expanded.
•
Broad
public understanding of risk factors, including systemic factors, will contribute to prevention. Risk assessment tools should have a dual
aim of ensuring an effective response to immediate threats and
long-term protection.
•
Risk assessment tools can be used by women themselves and in many other contexts, such as health and
social service provision, workplaces and schools, women-serving organizations,
men-serving organizations, and law enforcement.
•
Standardized
frameworks for assessments are valuable but must be adaptable to diverse
contexts.
•
The use of risk assessment tools needs to be continually monitored and evaluated.
WOMEN- CENTRIC RISK ASSESSMENTS
The Commission
recommends that
(a)
The federal
government should initiate and support the development of a common framework for women-centric risk assessments through
a
process led by the gender-based violence advocacy and support sector.
(b)
All agencies
responsible for the development and application of risk assessment tools integrate this common framework into their work in
collaboration with the gender-based violence
advocacy and support sector and on the basis of direct
input from women survivors.
(c)
The common framework
and the risk assessment tools built on this framework have a dual aim of ensuring an effective response
to immediate threats and
long-term protection.
IMPLEMENTATION POINTS
•
We support
the adoption and implementation of the Renfrew
County inquest jury recommendation 41:
41. investigate and develop a common framework for risk assessment in iPv [intimate partner
violence] cases, which
includes a common understanding of iPv risk factors
and lethality. This should be done in meaningful consultation and collaboration with those impacted
by and assisting survivors of
iPv, and consider key iPv principles, including victim-centred, intersectional,
gender-specific, trauma-informed, anti- oppressive, and evidence-based
approaches.
•
The common framework should be based on work done by the gender- based violence and advocacy
sector, including on
◇ the identification of risk factors and the integration of contextualized knowledge about
the patterns of perpetration, women’s
perspectives and experiences; and
◇
systemic factors that contribute to risk assessment tools used by all
agencies, including the police, primarily to assist women
to develop and carry
out effective safety
plans for themselves, their children, and other
dependants (family members,
pets, and livestock).
MAIN FINDING
The unacceptably low rate of reporting
of gender-based violence is a result of factors such as systemic barriers
rooted in the criminal justice system and the operation of racism, gender-based myths, and stereotypes; the complex
interactions among the criminal, family
law, and immigration law regimes; and the
fact that these systems do not adequately take into account the reality of women’s
lives. Many women fear disbelief by others, including the police, do not trust
that police will ensure their safety, and are concerned about being
criminalized or subject to other
state harms. These
barriers are heightened for marginalized women survivors.
LESSON LEARNED New
community-based systems for reporting gender-based violence must be developed
to respond to the safety needs articulated by women. Specific attention
must be paid to the needs of marginalized women survivors and the
needs of other
women who are vulnerable as a result
of their precarious status or situation.
CREATING SAFE SPACES TO REPORT VIOLENCE
The Commission
recommends that
(a)
Governments, service
providers, community-based organizations, and others engaged with the
gender-based violence advocacy and support sector take a systemic
approach to learning
about and removing
barriers to women survivors, with a focus on the diverse needs of
marginalized women survivors and the needs
of other women
who are vulnerable as a result of their
precarious status or situation.
(b)
Community-based
organizations, supported by governments, should develop safe spaces suited
to their community needs in which
women can report violence and
seek help.
(c)
Community-based reporting systems should include the capacity to
move beyond individual incidents and identify and address patterns
of violent behaviour.
(d)
Community-based
reporting systems should be linked with the police in a manner that takes into account the input and needs of women survivors.
MAIN FINDING Mandatory arrest and charging
policies and protocols
have often failed to keep women safe and have resulted
in unintended harms that in some
cases endanger women.
LESSON LEARNED
Mandatory arrest and charging policies
and protocols for offences arising from intimate partner violence should be abolished and replaced by a new women-centred framework that focuses on violence prevention rather than a carceral response.
REPLACEMENT
OF MANDATORY ARREST AND CHARGING
POLICIES AND PROTOCOLS FOR
INTIMATE PARTNER
VIOLENCE OFFENCES
The Commission
recommends that
(a)
Provincial and territorial governments replace mandatory arrest
and charging policies and protocols for intimate partner
violence offences with
frameworks for structured decision-making by police, with a focus on violence prevention.
(b)
The federal
government initiate and support a collaborative process that brings
together the gender-based violence advocacy and support
sector, policy-makers, the legal community, community safety and law
enforcement agencies, and other interested parties to develop
a national framework for a
women-centred approach to responding to intimate partner violence, including
structured decision-making by police that focuses on violence prevention.
(c)
Provincial and territorial governments, working with gender-based
violence advocacy and support sectors, develop policies and protocols for implementing this national framework to address jurisdiction-specific
needs.
IMPLEMENTATION POINT
•
One model worth
exploring in planning the national initiative is the approach taken in the development of the Canadian
Framework for Collaborative
Police Response on Sexual violence.
MAIN FINDING
Sexist
and racist myths
and stereotypes continue
to result in inef-
fective and inconsistent responses by police services to gender-based violence
– in particular to intimate partner violence and sexual assault cases.
LESSON LEARNED
External accountability mechanisms are
required to counter the prevalent sexist and racist myths and stereotypes about gender-based violence that result in largely
ineffective and inconsistent police responses.
EXTERNAL ACCOUNTABILITY MECHANISM FOR
POLICING RESPONSES TO INTIMATE PARTNER VIOLENCE
The Commission
recommends that
(a)
The federal
government support the gender-based violence
advocacy and support sector to
work with police services to expand upon the National Framework for
Collaborative Police Action on intimate Partner violence.
(b) This framework
should include an external accountability mechanism.
IMPLEMENTATION POINT
•
The improving
institutional Accountability Project
model or a similar
model should be considered.
MAIN FINDING
Coercive control is a pattern of violent
behaviour exercised by a member of intimate
partner or familial
relationships that is clearly problematic and poorly understood in Canadian society, including by the
police. Misconceptions about the nature of coercive
control and the harms that result from this behaviour contribute to a lack of
effective prevention, interventions, and responses.
LESSON LEARNED
A multifaceted approach
is required to enable effective prevention of, intervention in,
and responses to coercive control.
EFFECTIVE APPROACHES TO ADDRESSING
COERCIVE
CONTROL
AS
A FORM OF GENDER- BASED INTIMATE
PARTNER AND FAMI LY
VIOLENCE
The Commission recommends that
(a)
Federal, provincial, and territorial governments establish an expert advisory group, drawing on the
gender-based violence advocacy and support sector, to examine whether
and how criminal
law could better address the context of persistent
patterns of controlling behaviour at the core of gender-based, intimate
partner, and family violence.
(b)
The federal
government amend the Criminal Code to
recognize that reasonable resistance violence
by the victim of a pattern of coercive and controlling behaviour is self-defence.
(c)
Where they have not
already done so, provincial and territorial governments amend their family law
statutes to incorporate a definition of family violence
that encompasses patterns
of coercive and controlling
behaviour as a factor to be considered in proceedings under these statutes.
(d)
All provincial and
territorial governments work collaboratively with the gender-based violence
advocacy and support
sector, policy-makers, the legal community, community safety
and law enforcement agencies, and other
interested parties to develop educational and public awareness campaigns about
coercive control.
IMPLEMENTATION POINT
•
We support
the adoption and implementation of the Renfrew
County inquest jury recommendation 38:
Ensure that iPv [intimate partner
violence]-related public education campaigns address iPv
perpetration and should include men’s voices, represent men’s experiences, and prompt men to seek help to address
their own abusive behaviours. They should highlight opening the door to conversations about concerning behaviours.
MAIN FINDING Funding
related to preventing and effectively intervening in gender-based violence has
been inadequate for many years and, for that reason, endangers women’s lives.
LESSONS LEARNED
•
Community-based
services, and in particular services provided by the gender- based violence
advocacy and support
sector, need to be viewed in tandem with police agencies as equal partners in preventing violence. These services
are front-line public
services and are not discretionary.
•
Project-based funding is inefficient and causes lapses in effective preventive
and support services. Adequate and stable
core funding is essential for efficient and effective operation of
all organizations forming part of the public safety net in Canada.
EPIDEMIC- LEVEL
FUNDING FOR
GENDER- BASED
VIOLENCE PREVENTION AND INTERVENTIONS
The Commission
recommends that
Federal, provincial, and territorial funding
to end gender-based violence be commensurate with the scale of the
problem. it should prioritize prevention and provide women survivors with paths
to safety.
IMPLEMENTATION POINTS
•
Funding should
be adequate and include stable
core funding for services
that have been demonstrably effective in meeting the needs of women survivors of gender-based violence
and that contribute to preventing
gender-based violence, including interventions with perpetrators.
•
These services
should be funded
over the long term and should not be
discontinued until it has been demonstrated that the services are no longer required
or an equally effective alternative has been established.
•
Priority should
be placed on providing adequate
and stable core funding
to organizations in the gender-based violence advocacy and support sector.
•
A further priority
should be funding community-based resources and services, particularly in
communities where marginalized women are located.
Chapter 12 It Is Time: A Collective Responsibility to Act
MOBILIZING A SOCIETY-
WIDE RESPONSE
The Commission
recommends that
(a)
All levels
of government in Canada declare
gender-based, intimate partner, and family violence to be an
epidemic that warrants a meaningful and sustained society-wide response.
(b)
Non-governmental bodies,
including learning institutions, professional and trade associations, and businesses, declare
gender-based, intimate partner, and family violence to be an epidemic that warrants a meaningful
and sustained society-wide response.
(c)
Men take up individual and concerted action to contribute to ending this epidemic.
IMPLEMENTATION POINTS
•
A whole of society
response recognizes the range of actors that have roles and responsibilities to contribute to ending this
epidemic, including: federal, provincial, territorial, municipal, and
indigenous governments; the health
sector and the justice system; the non-governmental and community-based social
services sector; businesses, and workplaces;
media; schools and educational institutions; communities; and
individuals, including survivors and perpetrators.
•
A whole of society
response respects and values the expertise and experience of survivors and the gender-based violence advocacy and support sector.
WOMEN- CENTRED STRATEGIES AND ACTIONS
The Commission
recommends that
(a)
All organizations and
individuals adopt women-centred strategies and actions to prevent, intervene
in, and respond to gender-based violence, and to support restoration and healing;
(b)
Women-centred
strategies and actions be facilitated through the development and support of holistic, comprehensive, coordinated, collaborative, and integrated advocacy, support,
and services.
(c)
Women-centred
solutions focus foremost on taking active steps to listen to, learn from, and
situate the most marginalized and oppressed women and women living in
precarious circumstances.
IMPLEMENTATION POINTS
•
Recognition of the expertise and experience of the gender-based violence advocacy and support
sector, including survivors of gender-based
violence, is essential.
•
No effective solutions can be developed without input from the people
for whom they are being developed.
•
Tailored solutions
are required in recognition that there is no effective “one size fits all”
approach.
•
institutional and
personal dynamics that result in silencing women must be actively noticed,
identified, resisted, and remedied.
•
Women should be seen
as members of communities rather than in purely individualistic terms.
•
Approaches should affirm and support women’s agency.
PUTTING WOMEN’S SAFETY FIRST
The Commission
recommends that
(a)
All governments and agencies should
prioritize women’s safety
in all strategies to prevent, intervene in, and respond
to gender-based violence and in those designed
to support recovery
and healing.
(b)
Governments should
shift priority and funding away from carceral responses and toward primary
prevention, including through lifting women and girls out of poverty and
supporting healthy masculinities.
(c)
Governments should
take steps to ensure women are resourced so they can stay safe and find paths
to safety when they are threatened, including by lifting women and girls out
of poverty with a focus on marginalized and oppressed women and women living in
precarious situations.
(d)
Governments should
employ restorative approaches in cases where
a woman-centred approach is maintained and survivors are adequately
supported and resourced.
NATIONAL ACCOUNTABILITY FRAMEWORK
The Commission
recommends that
(a)
The federal
government establish by statute an independent and impartial
gender-based violence commissioner with adequate, stable funding, and effective
powers, including the responsibility to make an annual report to
Parliament.
(b)
The federal
government develop the mandate for the gender-based violence commissioner in
consultation with provincial and territorial governments, women survivors
including women from marginalized and precarious communities, and the gender-based violence
advocacy and support sector.
IMPLEMENTATION POINTS
The commissioner’s mandate could include:
•
Working with
governments and community organizations to promote coordinated, transparent,
and consistent monitoring and evaluation frameworks.
•
Providing a national
approach to victim-survivor engagement, to ensure their diverse experiences
inform policies and solutions (similar to the Australian Domestic, Family and
Sexual violence Commission).
•
Developing indicators
for all four levels of activity (individual, relational, community,
societal) and reporting to the public at least once a year.
•
Establishing and
working with an advisory committee that consists of women survivors, particularly marginalized women survivors, and representatives of the gender-based violence
advocacy and support sector.
•
Contributing to a
national discussion on gender-based violence, including by holding biannual
virtual women’s safety symposiums.
•
Assisting to coordinate a national research
agenda and promoting knowledge sharing.
Chapter 3: Rural Communities and Well-being
LESSONS LEARNED
Rural community well-being is
constrained by limited access to services, poverty, and under-inclusion, and in some cases, this nega-
tively affects the occupational health
and safety of rural service
providers.
Urban bias in policy-making and service delivery contributes to
inadequate public infrastructure and services in rural communities.
STRENGTHENING RURAL WELL- BEING THROUGH INCLUSION
The Commission
recommends that
(a)
Provincial and
territorial governments should take steps to address urban bias in
decision-making by fostering meaningful inclusion of rural communities in all areas affecting them.
(b)
The federal
government should support the inclusion of rural communities in decision-making
on issues within their jurisdiction.
Chapter 4: Framework for Community-Centred Responses
MAIN FINDING
Mass casualty incidents have a circle of
impact that extends beyond those whose lives were taken and those who are
injured. This broader circle encompasses families and friends of the deceased
and injured survivors; others present during the incident, including emergency
responders and other service providers; local communities; and the wider
population.
The nature and extent of the impact will vary within this
circle, and a differential impact has been shown to exist for individuals and
groups who have specific needs as a result of personal characteristics and
experience or are members of historically and contemporaneously marginalized or
stigmatized groups.
MAIN FINDINGS
Both directly and indirectly affected
individuals can experience a range of negative mental and
physical health outcomes following a mass casu- alty incident. Grief and
bereavement are normal, healthy processes, and these processes can be
facilitated through increased grief literacy and other forms of formal and
informal support. Traumatic loss can lead to complicated grief and a range of
post-traumatic stress injuries, including PTSD. Mass casualties can also result
in vicarious, secondary, and collective trauma.
MAIN FINDINGS
The Norwegian Aftermath
Study provides a strong empirical base for understanding the needs
experienced by those most affected by mass casualty incidents. This study
clearly demonstrates the persistence of need for financial support, material
support, and educational support for survivors of the Utřya mass casualty and their
families.
Eight years after
the incident, many people from among this group were still
experiencing high levels of PTSD, clinical levels of anxiety
and depression, physi- cal health challenges, difficulties
sleeping, and impaired daily functioning. Levels of unmet need increased over
time, and unresolved trauma experiences resulted in an increase in consumption of primary healthcare services both in the early and
delayed aftermath. Survivors
of minority background and young survivors
were differentially affected, experiencing profound long-lasting effects.
MAIN FINDINGS The
objectives of post–mass casualty incident assistance should be to support
the coping capabilities of individuals, families, and com- munities so as to enable them to recover,
to the greatest extent possible, and to foster
resilience despite traumatic loss.
LESSONS LEARNED Mass
casualty incidents are high-impact events that occur infrequently, making
it difficult for public safety
organizations to develop
exper- tise and train personnel to provide trauma-informed and
victim-centred services.
NATIONAL RESOURCE HUB FOR MASS CASUALTY RESPONSES
The Commissions recommends that
The federal government should establish, by September 2023, a
National Resource Hub for Mass Casualty Responses with a mandate to:
(a)
serve as a centre of
expertise for the provision of services to victims and affected persons,
including families and friends of victims, during and after a mass casualty;
(b)
draw on national and international experience, research, and promising practices;
(c)
build capacity across
all levels of government to plan responses to future mass casualty incidents
and respond effectively to victim needs in the short, medium, and long term,
including through the development of draft protocols, training modules, handbooks,
and other resources, and
a database of experts;
(d)
assist in the development of a standard
of victim response
across jurisdictions in Canada, while building in flexibility to respond in ways appropriate to the specific
community; and
(e)
facilitate the provision of assistance to victims, family members, and other
affected persons who reside outside
the jurisdiction where
the mass casualty took place (whether
in Canada or in another
country) and
facilitate assistance to foreign victims and affected persons,
including, for example, through cross-border support service referrals.
IMPLEMENTATION POINTS
•
The federal
government should consult
the Canadian Association of Chiefs of Police
National Working Group
Supporting victims of Terrorism
and Mass violence; their relevant
indigenous, provincial, and territorial
counterparts; the Canadian Resource Centre for victims of Crime; other victims’ rights
advocacy organizations; provincial victims’ services
programs; and the Federal Ombudsman for victims of Crime.
•
The expertise
developed by this National Resource Hub for Mass Casualty Responses could
extend to other types of emergency and major incident response.
•
The National Resource Hub could also assist directly in training personnel, and could potentially establish a small
national team to be mobilized quickly in response to a mass
casualty.
Chapter 5: Public Warning Systems
AMENDING THE CANADIAN
DISASTER DATABASE TO INCLUDE MASS CASUALTY INCIDENTS
The Commission recommends that
The Minister of Public Safety Canada amend the categories of
events used in the Canadian Disaster
Database to include
mass casualty incidents
as defined in Recommendation
v.1: “An intentional act of violence during which one or more perpetrator(s)
physically injure(s) and/or kill(s) four or more victims, whether or not known to the perpetrator,
during a discrete period of time.”
LESSONS LEARNED Alert
Ready is circumscribed by challenges and limitations that exist beyond the systemic failures
of the RCMP to consider
its use during
the mass casualty.
A fundamental review and redesign
of the national public alert
system is required.
A community-centred system
of alert systems
is required to fully meet public
needs.
FUNDAMENTAL REVIEW OF ALERT READY
The Commission
recommends that
The federal, provincial, and territorial governments should
undertake a fundamental review of public emergency alerting to determine
whether and how the Alert Ready system can be reformed in such a way that it
meets the legal responsibility to warn the population of an emergency that
threatens life, livelihoods, health, and property.
This joint governmental review of the national public alerting
system should be comprehensive and at a minimum address the following:
(a)
it should
include substantive community and stakeholder engagement at all stages.
(b)
it should establish a
national framework for public alerting, led by Public Safety Canada, with
operationalization to continue on a provincial, territorial, and indigenous government basis but pursuant
to national standards. it should restructure in order to transition from reliance on a
private corporation as the provider
of Canada’s national
alerting system.
(c)
it should be completed
in advance of and inform the next round
of negotiations with the licensee
/ candidates and be taken into
consideration in any renewal issued
before the completion of the review.
(d)
it should be based on
the following system design principles: centring the public; building a system
of systems; enhancing governance; formulating a concept of operations;
protecting privacy; focusing on preparedness;
assuring equality and inclusiveness; and promoting continuous
learning and improvement.
(e)
it should
include a comprehensive review of communications interoperability across
the public safety system.
IMPLEMENTATION POINT
•
Consideration should
be given to the value
of establishing a national
emergency management system.
LESSON LEARNED
Effective public alert systems require
an ongoing iterative learning process.
TRIENNIAL
REVIEW OF THE NATIONAL
PUBLIC ALERTING SYSTEM
The Commission
recommends that
The senior officials responsible for emergency management
undertake
a review of the national
public alerting system
every three years
and that a report on the process and findings of
this review be made public.
The review include a public-engagement component, including a national
poll about the awareness and assessment of the national public alerting
system.
The review take into consideration the
diverse needs of people living in Canada,
including urban, rural, and remote communities, official language minorities,
and marginalized communities.
Chapter 6: Meeting the Needs of Survivors and Affected Persons: Police-Based
Services
LESSONS LEARNED
Ensuring that the basics of victim
support are solidly in place and that interoperability between emergency responders is effective and well-established will enable the scaling up of critical
incident response in the
event of a mass casualty.
Numerous previous inquiries, reviews, and reports
have identified inadequacies and limitations in the RCMP provision of information and other services
to victims and other affected
persons.
RCMP policies and training with respect to next of kin
notifications and the role of family liaison officers are inadequate.
RCMP institutional culture should value services provided to
survivors and affected persons as significant police work essential to public
safety and commu- nity well-being.
Advance planning is required to scale up victim services to meet
the needs of survivors and other affected persons during and after a critical
incident. Addi- tional protocols and expertise are required to meet the demands
resulting from these incidents.
REVITALIZING POLICE-
BASED VICTIM
SERVICES WITH A DUTY OF
CARE
The Commission recommends that
(a)
The RCMP and other
police services adopt policies recognizing a duty of care in the provision
of services to survivors and affected persons.
(b)
All police
personnel communicating with survivors and affected persons do so pursuant to trauma-informed
and victim-centred principles, and that they receive the education, mentoring, and support required to integrate
these principles effectively.
(c)
RCMP policies, protocols, and training recognize the priority of
providing to survivors and affected persons
full and accurate
information at the earliest opportunity, including through
regularly scheduled contact updates even where there
is no new information to provide.
(d)
Any holdback of
information for investigative purposes should be limited in time and scope to
that which is truly necessary to protect investigative integrity.
(e)
The RCMP update its
description of the role and responsibilities of family liaison officers in consultation
with subject matter experts and
integrating lessons learned
and feedback received
from Participants at the
Commission.
(f)
The RCMP should review
and revise its next of kin notification policy and protocols and design an education module
to facilitate its implementation.
(g)
The RCMP take steps
necessary to ensure these policies and their implementation fully meet or exceed Nova Scotia policing
standards.
IMPLEMENTATION POINTS
•
Preservation of
victim dignity should be a priority, including through taking steps to ensure
victim’s bodies are secured, covered as quickly as possible, and protected such that video
footage and photographs cannot be taken.
•
RCMP policies,
protocols, and training should recognize that in order for the family
liaison officer to succeed, their
colleagues (e.g., those
in the Major Crimes Unit)
must support them by providing accurate and timely information.
•
A family liaison
officer should offer meaningful updates and guidance about the investigation, as well as general information on related offices and services—including, but not
limited to, the medical examiner, insurance,
crime scene and evidence cleaning, and mental and physical
health supports.
LESSONS LEARNED The
provision of information and services to survivors and affected persons
is an indispensable part of community-centred critical incident responses and should be integrated into critical incident
planning and management.
Services for survivors and affected persons cannot be scaled up
during or in the immediate aftermath of a critical
incident without preplanning and preparedness,
including through education and table-top exercises as required.
During a critical incident, the communication of information
flows in two direc- tions: from the public safety system to individuals,
families, and the communities, and vice versa.
POLICE-
BASED SERVICES FOR PERSONS
AFFECTED BY
MASS CASUALTIES
The Commission recommends that
(a)
Critical incident
command groups should
include a member
dedicated solely to victim
management and that the critical
incident plan include a victim crisis response
component to meet the information needs of survivors and affected persons
during a major event or emergency.
(b)
The victim crisis
response should include: a dedicated telephone line for individuals seeking
information about family or friends; a website platform; a multidisciplinary victim response team; and protocols and
guidelines, including for the establishment of a family assistance centre.
(c)
The time standard for mobilizing the victim management response plan should be 90 minutes from the time a critical incident response is
activated.
(d)
victim management response should be a component
of annual table-top critical incident response
preparedness exercises.
(e)
Upon request, the
National Resource Hub for Mass Casualty Responses (Recommendation C.2) assist
municipal police forces to build their
capacity to activate a victim management response to a critical
incident, including by developing model protocols, a website plan, training modules, and other tools.
Chapter 7: Meeting the Needs of Emergency Responders
MAIN FINDING Many emergency responders, including first
responders such as police, firefighters, paramedics, and
other emergency health personnel, work in high
psychological risk environments on a daily
basis. Proactive and preventive
approaches are required to mitigate these risks and to help prepare responders for
the potential impact of critical incidents.
MAIN FINDING
Perceived organizational support is the extent to which employ-
ees feel that their organization values their work and cares for their well-being.
Where an emergency
responder perceives a lack of organizational support,
they are at a higher risk of experiencing post-traumatic stress
symptoms.
MAIN FINDING
Emergency responders have
a tendency to deny and downplay the need for support and delay help-seeking behaviour. Stigma, lack of awareness of support resources, lack of
confidentiality, and stoicism are obstacles to healthy help-seeking behaviour.
LESSONS LEARNED
Planning for and taking steps to ensure
the wellness of emergency responders as they carry
out their everyday
duties and to prepare
them for the heightened stress and potential trauma of high-impact events is an
important aspect of community-centred critical
incident response.
Proactive and preventive wellness approaches should be holistic
and engage a whole-of-agency discussion.
Public safety agency leadership has a critical role to play in
ensuring that all responders are accorded equal organizational support and in
prioritizing the eradication of barriers to healthy help-seeking behaviour.
Recognizing that families
of emergency responders are affected and that experi- ences and family dynamics
may change over time, the education about
wellness and awareness of organizational supports must be continuous.
PROACTIVE PRE- CRITICAL INCIDENT WELLNESS PLANNING
The Commission
recommends that
(a)
All public
safety agencies should
develop and promote
pre-critical incident wellness planning.
(b)
All public safety
agencies should develop wellness programming that is proactive and preventive in nature.
(c)
The leadership of
public safety agencies should take proactive steps to ensure that all responders are accorded equal
organizational support and to promote healthy help-seeking
behaviour.
(d)
Public safety
agencies in each jurisdiction should collaborate to provide training, including
tabletop exercises, to civilian members of the responder community, including
volunteers, as one aspect of their pre–critical incident planning.
IMPLEMENTATION POINTS
Proactive and preventive wellness programs should address the
following areas:
•
pre-critical incident planning and
training;
• integrated and intensive
training to develop
skills and build awareness
about mental wellness (such as the Before Operational Stress Program and breathing
techniques to modulate stress);
• enhanced mental health training for supervisors and officers, to
promote cultural change;
• peer support programs,
supported by evidence-based training, that take hierarchy into account, matching
experience to experience, and ensure that a diversity of peer supporters are available to connect;
• effective informal peer support and for peer support to spouses
and families of responders;
•
readily available information and knowledge about the resources
for peers; and
•
active facilitation of help-seeking behaviour, including by:
◇
addressing stigma;
◇
increasing and ongoing awareness
about resources;
◇
enhancing confidential options;
◇
raising awareness about problematic forms of stoicism;
◇
openly acknowledging the difficult
work;
◇ promoting effective workplace policies making supports
available, including in the discussion those who should play a role in these sup- port
systems; and
◇
providing evidence-based supports.
MAIN FINDING Due
to systemic inadequacies and limitations, Nova Scotia public safety agencies
did not fully meet the needs of all emergency responders who attended to the
April 2020 mass casualty and its aftermath. The experience has been highly varied:
Some responders report
being highly satisfied with the services
received and others continue to have unmet needs for support services.
MAIN FINDING
Some emergency responders, and
particularly volunteer fire- fighters and Operational Communications Centre personnel, have chronic unmet needs for support services.
MAIN FINDING
Many emergency responders continue to be
affected by their experience during and after the mass casualty. Evidence from other
mass casu- alty incidents
suggests that these effects can last for many years.
LESSONS LEARNED Many
emergency responders require support and wellness services following
a mass casualty. Access to these services
depends upon the capacity of the agency, and this
capacity is not always aligned with the needs
of emergency responders. The effects of a mass casualty may compound pre- existing traumas often inherent
in an emergency responder’s work.
Cultural and institutional factors can hinder
emergency responder support- seeking strategies both on an
everyday basis and in response to critical incidents.
Mass casualty incidents create additional challenges to the
ability of agencies and organizations to provided support services to emergency
responders. These challenges result from the scale
and nature of these incidents and the cross- agency response required to meet them.
POST–MASS
CASUALTY INCIDENT
EMERGENCY RESPONDER MENTAL
HEALTH LEAD
The Commission recommends that
immediately following a mass casualty
incident, the provincial government should appoint a mental health point person to
coordinate the mental health leads in each division or agency that responded to the incident.
This liaison role would have the responsibility to oversee and evaluate the provision of confidential support services to
emergency responders from all agencies and the
informal sector, and to promote
their wellness.
IMPLEMENTATION POINTS
The mandate of the mental health
lead would include
the following tasks:
• establish and maintain regularly scheduled contact with
emergency responders in the aftermath of the incident;
•
coordinate and convene cross-agency debriefings;
• take steps to ensure a continuum of care to responders in the immediate, short and long term;
• advise the leadership of public safety agencies on issues that affect
personnel mental health (including work and shift assignments);
• liaise with the post-incident support lead (Recommendation C.12)
to coordinate the provision of service to emergency responders whose needs
cannot be met through public safety agencies;
•
advise the provincial government concerning unmet needs;
and
• evaluate the impact of the mass casualty on emergency responders
and provide advice to public safety
agencies, other employers, and the provincial government concerning steps to
be taken to better meet wellness needs.
Post–critical incident
wellness plans should
include:
• provision for relief workers
to relieve emergency
responders affected by the critical incident;
• changes to leave policies
to facilitate emergency responders taking the time
required to meet their wellness needs;
•
the opportunity to jointly debrief after a critical incident;
• provision for more in-person meetings
and communication in the post-
incident period;
• sufficiency of support resources, both regularly and over a longer period of time;
• uniformity in support resources for emergency responders (including civilians)
across agencies;
•
facilitation of on-site support
for responders;
• coordination of supports within public
safety agencies to facilitate access by emergency responders;
• resources for in-house wellness units following a mass casualty to meet
the additional demands; and
• training for coach officers / supervisors / managers / leaders to ensure proactive support of emergency responders with
up-to-date information about available mental health supports and understanding
of the issues facing emergency responders members on
the ground.
Chapter 8: Meeting
the Support Needs of Affected Persons and Communities
MAIN FINDING
Nova Scotia Health Authority Mental
Health and Addictions Pro- gram and
Nova Scotia victim Services took steps to meet the immediate needs of affected persons and communities
through a range of initiatives undertaken
in partnership with iWK Health
Centre and other
partners. These services
did not fully meet the
support needs following the April 2020 mass casualty.
The extent of unmet need cannot be measured because
a needs assessment has not
been carried out nor has there been an evaluation of the support services
provided to date.
MAIN FINDING Factors that limited
the effectiveness of support services
include the lack of knowledge about support needs, lack of community
awareness about and accessibility of services, rural
healthcare scarcity and scarcity of mental
health services, a misalignment of needs and services provided, failure to
provide spaces for the sharing of experiences among affected community members,
insufficient attention to grief and trauma, lack of coordination between service
providers, and lack of continuity in services.
MAIN FINDING
COviD-19 and the work of the Mass
Casualty Commission were compounding factors that affected the need for and access to support
services.
LESSON LEARNED
The Nova Scotia and Canadian
healthcare systems do not
adequately integrate mental health care within the organization and delivery of healthcare services. These systemic
inadequacies contributed to the inability of the Nova Scotia Health Authority to adequately respond to the mental health
needs of those
affected by the mass casualty.
Members of Nova Scotia rural communities experience chronic
limitations on access to health and social services. These limitations
compounded the problems in access that many residents have experienced, and
continue to experience, in the aftermath of the mass casualty.
MAINSTREAMING
AND INCREASING AVAILABILITY OF MENTAL HEALTH SERVICES
The Commission
recommends that
Federal, provincial, and territorial governments should develop
a national action plan to promote better integration of preventive and
supportive mental health care into the Canadian
healthcare system, so as to ensure greater
access to these services on an equal level as physical healthcare.
LESSON LEARNED Many Nova Scotians and other Canadians have not been provided with the resources needed
to foster grief, bereavement, trauma, and resiliency literacy. This lack
hinders the ability of individuals and families to develop healthy
coping strategies following a mass casualty, including through seeking formal and informal
support and assistance.
ENHANCE GRIEF, BEREAVEMENT,
TRAUMA, AND RESILIENCY LITERACY
The Commission
recommends that
(a)
The Nova Scotia
Health Authority, in consultation with community-based health organizations and service providers in the affected communities,
should develop a public education and awareness campaign to foster
greater literacy about grief, bereavement, trauma, and resiliency.
(b)
Other Canadian health
authorities, in consultation with community-based health organizations and service providers, should take steps to increase
grief, bereavement, trauma, and resiliency literacy.
IMPLEMENTATION POINT
•
These education and
awareness campaigns should include ongoing education in schools. Consideration should also be given to include
them alongside existing programs – for example, as a requirement for workplaces as part of workers compensation programs.
LESSONS LEARNED
Mass casualties give rise to extensive
individual and community needs for a range
of health and social service
supports that require existing systems to scale
up their capacity
on an urgent basis.
Preplanning and preparedness is
required to enable an effective community- centred response for the provision
of support services to affected individuals and communities in the immediate, short, medium, and long term.
Post-critical incident support plans and protocols should be
developed during the preparation phase and liaisons should be established to
ensure a smooth transition to this plan as soon as practicable following a
critical incident.
Like all aspects of community-centred critical incident
response, the support service plan requires community engagement and
relationship building during the preparedness phase.
Plans ensure a rapid and sustained response that includes the
capacity to assess need from the perspective of those affected; effective
systems for ensuring awareness about and accessibility of services; and the
capacity to scale up support services by making additional resources available
to meet immediate, short-, medium-, and long-term needs.
POST- MASS CASUALTY INCIDENT SUPPORT PLANS
The Commission
recommends that
(a)
Health Canada, in
consultation with provincial and territorial health authorities and subject matter experts, should develop a national policy, protocols, and program to provide
a range of health and social support services required by those most affected
by a mass casualty, both for individuals and for communities as a whole.
(b)
The national policy and
protocols should establish a national standard that can be adapted
to the specific circumstances of the mass casualty,
and the program should include allocations of funding to support their implementation.
(c)
The national standard
for post-mass casualty incident support plans should be developed on the basis of, and integrate, these guiding
principles:
(i)
respectful treatment
of those most affected, including through recognition of their unique
perspective, experiences, and needs and their involvement in the
implementation of the post–critical incident support plan;
![]()
(ii) recovery and resilience established as the desired
outcomes;
(iii) trauma-informed and victim-centred service provision;
(iv)
proactive, comprehensive, and coordinated support
services that include
navigation assistance;
(v)
commitment to
providing services in the immediate, short and medium, and long term; and
(vi)
ongoing needs
assessments, monitoring, and periodic evaluation of programs and services.
(d)
One of the national
protocols should provide
that a multidisciplinary team be established and mobilized within 24
hours to assist local service
providers to initiate a support plan immediately following a mass casualty.
(e)
The protocols for
post-mass casualty incident support plans should provide for the designation of a post-incident support lead with the
responsibility to coordinate the implementation of the plan, including through adapting
it to the specific circumstance of the mass casualty.
(f)
The national program
should liaise with the National Resource Hub
for Mass Casualty
Responses (Recommendation C.2) to develop
and
operationalize a knowledge exchange network to facilitate the sharing of promising practices, research, and
evaluations across Canada, including through
monitoring international developments in post-critical incident support planning and service
provision.
IMPLEMENTATION POINTS
•
Service providers
should receive training to enable theme to provide support services following a
mass casualty, including through modules to support the wellness of service
providers who are engaged in this work.
•
The national policy
and protocols should include the issue of the financial assistance required
to support affected
persons and communities.
•
The national policy
and protocols should include designated liaisons for directly affected
family members who live elsewhere
in Canada, beyond the jurisdiction of the mass
casualty, or outside Canada.
•
Trauma-informed
training should be integrated across public sector service delivery
and be made available to community-based organizations.
Chapter 9: “We Will Write
Our Own Story”
LESSONS LEARNED The
Province of Nova Scotia has not fully met the needs of the communities most affected by the April 2020 mass casualty, resulting in a
health deficit and public health emergency.
The long-term impact of unresolved complicated grief and traumatic loss can be devastating to individuals and is counter
to the community deep-seated need to
build a positive community legacy.
REVERSING THE COURSE:
ADDRESSING THE PUBLIC HEALTH EMERGENCY IN
COLCHESTER, CUMBERLAND, AND HANTS COUNTIES
The Commission
recommends that
(a)
By May 1, 2023,
the Governments of Canada and Nova Scotia
should jointly fund a program
to address the public health emergency that exists in Colchester, Cumberland,
and Hants counties as a result of an unmet need for mental health, grief, and
bereavement supports arising from the April 2020 mass casualty.
(b)
This program should be developed and implemented by a local
multidisciplinary team of health professionals with the ability to draw on external
resources as needed.
(c)
The program should
provide concerted supports on an urgent basis and transition to long term care
over time.
(d)
Mi’kmaw communities should have the opportunity to participate in the
program either on a joint or an independent basis.
(e)
The program should be
funded to carry out needs and impact assessments in 2023, 2025, and 2028.
IMPLEMENTATION POINTS
•
The program should consult with members of marginalized groups living
in the
most affected communities to determine how to best meet these
needs.
•
The plan should
include assessing and meeting the needs of women at Nova institution for Women who have been affected
by the mass casualty.
•
Organized and supported peer-to-peer networks should be developed as one element of this plan,
•
To the extent that
sufficient resources are available, consideration should be given to the
provision of services in other parts of the province.
Chapter 10: From Community-Based Policing to Community Safety and Well-being
LESSONS LEARNED
Early iterations of community-based
policing models failed to live up to their promise because of a range of
institutional, cultural, and societal factors.
This early model was based on a flawed concept of what
constitutes police community relations and a flawed premise that police-led
directives and initia- tives alone could be the basis of a shared understanding
of the requirements for community safety.
Community-based policing
failed to become
entrenched in policing
culture.
The concept of community policing
needs to be transformed and replaced by a
focus on community safety and well-being recognizing the primary role of other institutions and agencies, including community-based organizations.
The community, not the police,
needs to be at the centre of a modernized com- munity safety and well-being model, with the police serving
as a collaborative partner, not as the primary actor in this social system.
The economics of policing requires a broader discussion through
the lens of the economics of community safety and well-being.
Chapter 11: Facilitating Community Engagement
ENACTING COMMUNITY SAFETY AND WELL- BEING LAWS
The Commission
recommends that
(a)
The federal
government should enact legislation within six months to create a statutory framework designed to support and enhance
community safety and well-being in every province and territory.
This national framework would be based on guiding
principles central to the
delivery of public services that include:
(i)
the centrality of a
commitment to equality and inclusion as foundational principles for community
safety and well-being;
(ii) a prevention-first approach to safety;
(iii)
an understanding that social determinants of health are also the social determinants of community
safety and well-being;
(iv)
an understanding that
police and corrections are layers of this approach to community safety
and well-being as decentred and collaborative partners;
(v)
community-informed
municipal / provincial/territorial multi-sectoral processes to ensure more efficient collaboration between different
agents of community safety and well-being;
![]()
(vi)
an essential focus on
community engagement, including input from and consultation with historically
overpoliced communities, in any legislative initiative focused on community
safety and well-being; and
(vii)
the sharing of
personal information between public sectors (including police, education,
health, social services, and corrections) when necessary to achieve the success of these community
safety and well- being initiatives, while respecting
the privacy rights of an individual.
(b)
Where they have not already done so, provincial and territorial governments should
each enact laws within a year to create a statutory
framework for community safety and well-being initiatives. These frameworks
should include provision for:
(i)
the establishment within a year of a Community Safety
and Well- Being Leadership Council composed of leaders from all sectors, including non-police sector partners
(e.g., leadership from health and community-based organizations,
gender-based violence advocacy and support sector, historically marginalized
communities). This council would be parallel to the federal counterpart and
include liaison or joint members.
(ii)
municipalities
(individually or jointly) to prepare and adopt community safety and well-being
plans in partnership with a multi- sectoral advisory committee;
(iii)
community safety planning to address four areas: social development,
prevention, early intervention, and incident response;
(iv)
engagement, collaboration, and communication between the community,
groups, agencies, and service providers;
(v)
community engagement,
beginning with the development of comprehensive community safety needs assessments,
followed by information sharing, awareness raising, and involvement in specific
actions and strategies under the plan;
(vi)
the sharing of
personal information between public sectors (including police, education,
health, social services, and corrections) when necessary to achieve the success of these community
safety and well- being initiatives, while respecting
the privacy rights of an individual; and
(vii)
each community, province, and territory, in alignment with the
fundamentals of a national framework, to fashion localized frameworks to best meet the unique needs and circumstances of their
communities.
(c)
Federal, provincial,
and territorial governments should ensure these laws are supported by adequate
long-term public funding
that puts crime prevention on an equal footing with enforcement of the criminal law.
COMMUNITY SAFETY AND WELL- BEING LEADERSHIP COUNCIL
The Commission
recommends that
To further strengthen federal, provincial, and territorial initiatives that may already be
underway, we recommend that the federal legislation include the establishment
within a year of a Community Safety and Well-Being Leadership Council composed
of leaders from all sectors,
including non-police sector partners (such as health
and community-based organizations, gender-
based violence advocacy and support sector, and historically
marginalized communities). This council should not be driven by any one
organization but should facilitate shared
responsibility for addressing social issues. it should
(a) formulate strategies
for addressing social issues together;
and
(b)
lead a multi-sectoral approach
that centres prevention by collaboratively
addressing the social determinants of community safety and well-being.
COMMUNITY SAFETY AND WELL- BEING FUNDING ALLOCATION
The Commission
recommends that
Federal, provincial, and territorial governments should
(a)
adopt funding
allocation methods for community safety and well-being initiatives that take into account rural and remote
contexts, and
(b) shift budgets
to focus on prevention activities.
IMPLEMENTATION POINTS
These laws should
•
recognize gender-based, intimate partner, and family violence
as a central inhibitor of community safety and well-being;
•
prioritize safety and
well-being in marginalized communities, recognizing the past and ongoing
collective trauma resulting from systemic racism, colonialism, and other processes
of marginalization and oppression; and
•
ensure that rural communities have an active role in planning for safety and well-being in their communities.
The laws should be accompanied by public and institutional
education on community safety and well-being to ensure that there is an
understanding of the correlation between properly funding initiatives for prevention and increased
overall community safety This public and institutional education should explain
that current funding is being applied in fragmented ways in
different government departments and agencies but would be more efficiently used if coordinated under
an overall approach. it should reinforce the concept of the economics of community safety and well-being, that is, that the
responsibility and economic
weight for public safety does not rest solely at the
feet of, or in the hands of, the police.
Community Safety and Well-Being
Leadership Councils should
•
assist municipalities,
provinces, and territories to build and sustain local multi-sectoral approaches at the service delivery
level through the establishment of partnerships among multi-agency teams; and
•
support information-sharing and coordination across sectors
through mechanisms such as regular meetings, frequent informal communication,
co-location of services, and cross-agency secondments.
Monitoring and evaluation mechanisms should be adopted with a defined timeline for implementation:
•
Community safety and
well-being initiatives should be evidence-based and best-practice informed.
•
The design of
community safety and well-being plans should include provision for longitudinal
studies, data sharing among all partners, as well as metrics to assess the
impact and outcomes and processes for
monitoring and evaluation, and to identify the
most promising actions and strategies.
•
A national strategy
is needed to support research-based community action and to build
community capacity.
All governments should
adopt the main features of the recommendations for public service reform made by the Scottish Commission on the Future Delivery
of Public Services
(chaired by Dr. Campbell Christie):
People: Reforms must aim to empower
individuals and communities by involving them in the design
and delivery of the services.
Partnership: Public service
providers must work more closely in partnership, integrating service provision
to improve their outcomes.
Prevention: Expenditure must be
prioritised on public services which prevent negative outcomes.
Performance: The public services system – public, non-profit and private
sectors – must reduce duplication and share services to become more efficient.*
* Scottish
Government, Commission on the Future Delivery of Public Services, Dr. Campbell
Christie, Chair (June 2011).
Chapter 12: Rethinking Roles and Responsibilities
LESSONS LEARNED Bystander
intervention is an effective means to prevent gender-based, intimate
partner, and family
violence, and individuals of all ages should understand how to safely
employ this strategy when they learn about or witness these situations.
Cultural, social, individual, and situational factors act as
barriers to effective bystander intervention.
PROMOTING
BYSTANDER INTERVENTION AS A DAI LY PRACTICE
The Commission
recommends that
(a) The federal
government should:
(i)
renew and extend bystander intervention awareness and education
campaigns and support their implementation in a wide range of settings,
including in education, in workplaces, and in the provision of public services;
and
(ii) develop and implement a longitudinal evaluation of these campaigns.
(b)
Provincial and
territorial governments should develop and implement a mandatory gender-based
violence and bystander intervention training curriculum in the school system
commencing in kindergarten and continuing until Grade 12.
(c)
Municipal,
provincial, territorial, and indigenous governments should develop and
implement gender-based, intimate partner, and family violence bystander
intervention training for their workplaces and staff.
(d)
Colleges, universities, and other education and training institutions and workplaces, to the extent they are not already doing so, should provide
practical training in support of effective and safe bystander
intervention.
IMPLEMENTATION POINTS
•
These campaigns and programs should
be designed to effectively
counteract cultural barriers to bystander intervention.
•
These campaigns
and programs should be designed
to effectively prevent violence in the moment and address
social and cultural factors that contribute to condoning gender-based violence.
•
These campaigns, programs, and evaluations should be developed and implemented in collaboration with the gender-based violence advisory and
service sector.
•
These campaigns,
programs, and evaluations should be developed and implemented in collaboration through
community engagement processes, particularly with members of
marginalized communities and with rural communities.
LESSONS LEARNED Businesses have important roles and responsibilities as part of a whole of society response
to gender-based, intimate
partner, and domestic violence.
These responsibilities include ensuring that workplaces are safe
and promote well-being, supporting
employees who are dealing with violence outside of the workplace, being
an active part of the community safety
ecosystem, and contrib- uting more generally to the
promotion of gender equality and inclusion.
BUSINESSES
AND INDUSTRY ASSOCIATIONS CHAMPIONING
ENDING GENDER- BASED
VIOLENCE
The Commission recommends that Businesses should:
(a)
undertake a
self-assessment of how effectively their existing policies, programs, culture,
leadership, and strategy are tackling violence and harassment and supporting
survivors and bystanders and whistleblowers;
(b)
undertake a self-assessment of how effectively their existing
policies, programs, culture, leadership, and strategies are addressing violence
and harassment committed by their employees;
(c)
commit to a leadership role in fostering cultural shifts that challenge the normalization
of gender-based violence and integrate this shift into their business
practices; and
(d)
play an active role in the development and implementation of community
safety and well-being plans.
LESSONS LEARNED
Traditionally, professional licensing
bodies regulate their licensees through an individual complaints-based system that is insufficiently
proactive.
Community safety and well-being can be promoted
through more proactive monitoring of licensees.
Members of marginalized communities are particularly at risk of
being subjected to poor treatment and unethical or illegal behaviour.
PROACTIVE
MONITORING BY PROFESSIONAL
LICENSING BODIES
The Commission
recommends that
All professional licensing bodies should:
(a)
monitor their members
proactively to better ensure the safety and well- being of their licensees’
clients / patients;
(b)
through careful
monitoring, track and proactively demand accountability
when discernible patterns
of unethical or illegal behaviour
are uncovered; and
(c)
take steps to promote awareness of complaints mechanisms,
including by requiring that licensees prominently display the Code of Ethics and information about the complaints process in their offices / clinics and online.
IMPLEMENTATION POINTS
•
Practice audits and
quality control systems can assist in proactive monitoring.
•
Professional licensing bodies should:
◇ acknowledge that marginalized communities face barriers to
report- ing concerning behaviour; and
◇ take steps to minimize these barriers through engagement with
these communities.
OVERSIGHT
OF PUBLICLY FUNDED
SERVICES TO POOR AND MARGINALIZED COMMUNITIES
The Commission
recommends that
All levels of government should monitor the provision of public health services by independent service providers to
people of lower economic means (and those who are otherwise marginalized) to ensure that quality services
are being delivered in compliance
with professional standards, including ethical codes.
Governments should work in partnership with professional regulatory bodies for this purpose.
ACCESS TO FIREARMS AND COMMUNITY SAFETY
Chapter 13: Access to Firearms and Community Safety
LESSON LEARNED
Priority should be placed on reducing
access to the most dangerous, high-capacity firearms and ammunition in
recognition of the risks they pose and the fact they do not serve a hunting
or sporting purpose.
REDUCING GUN LETHALITY
The Commission
recommends that
(a)
The federal
government should amend
the Criminal Code to prohibit
all semi-automatic handguns and all semi-automatic rifles and shotguns
that discharge centre-fire ammunition and that are designed
to accept detachable
magazines with capacities of more than five rounds.
(b)
The federal
government should amend the Criminal Code
to prohibit the use of a magazine with more that five rounds so as to close
the loopholes in the existing law that permit such firearms.
(c) The federal government should amend the Firearms Act
(i) to require a licence to possess ammunition;
(ii) to require
a licence to buy a magazine for a firearm;
and
(iii)
to require
a licensee to purchase ammunition only for the gun for which they are licensed.
(d)
The federal government should establish limits on the stockpiling of
ammunition by individual firearms owners.
(e)
The federal government should reform the classification system for firearms and develop a standardized schedule
and definitions of
prohibited firearms within
the Criminal Code of
Canada, with an emphasis
on simplicity and consistency.
(f)
The federal
government should take steps to rapidly reduce
the number of prohibited semi-automatic firearms in circulation in Canada.
LESSON LEARNED
The safety of women survivors of
intimate partner violence is put at risk by the presence
of firearms and ammunition in the household.
REVOCATION
OF
FIREARMS LICENCES FOR CONVICTION
OF GENDER- BASED, INTIMATE PARTNER, OR FAMI LY VIOLENCE
The Commission
recommends that
(a)
The federal
government should amend the Firearms Act to
automatically revoke the firearms licences of persons convicted of domestic
violence or hate-related offences.
(b)
The federal
government should amend the Firearms Act to suspend
the firearms licences of persons charged
with such offences; where such charges are diverted, withdrawn, stayed, or otherwise resolved without trial,
the suspension should remain in place and the burden of proof should be on licence holders
to demonstrate they are not a risk or a threat to others.
(c)
The federal
government should consult
with indigenous groups,
the gender-based violence advocacy and service sector representatives of
rural communities, firearms
officers, and police
services to create
guidance for the consistent, effective, and safe enforcement of these provisions.
IMPLEMENTATION POINT
•
We endorse jury
recommendation #13 of the Ontario Office of the Chief Coroner’s 2022 inquest
into the murders of Carol Culleton, Anastasia
Kuzyk, and Nathalie Warmerdam (the Renfrew County inquest). This
recommendation would require all police services to immediately inform the
chief firearms officer (CFO) of charges related to intimate partner violence
after they are laid, and provide any relevant records, including Firearms
interest Police information collected for the police database and used by chief
firearms officers to screen applicants for firearms licences.
LESSON LEARNED
The current firearms regime does not
adequately protect against the unlawful
transfer of firearms
upon the death
of the owner.
PREVENTION OF UNLAWFUL TRANSFERS OF
FIREARMS FROM ESTATES
The Commission
recommends that
The federal, provincial, and territorial governments should enact legislative and regulatory changes
required to prevent unlawful transfers of firearms from estates.
IMPLEMENTATION POINTS
•
Create mechanisms to transfer information from government databases such as vital Statistics to
firearms officers, which would ensure that firearms officers receive immediate notification of a death or licence expiry and take action to identify, retrieve, and secure firearms.
•
Educate those administering an estate about
their responsibility for the
timely and legal deactivation, surrender, or destruction of firearms in the estate and hold them accountable.
LESSON LEARNED Effective
border control requires a collaborative and coordinated approach among border
agencies with interoperable systems for the sharing of records and information.
INTEROPERABILITY
OF
LAW ENFORCEMENT AGENCIES ENGAGED IN FIREARMS CONTROL AT THE
CANADA–UNITED STATES BORDER
The Commission
recommends that
(a)
All law enforcement
agencies with a shared mandate to stop the illegal entry of firearms into
Canada should develop fully interoperable systems for the sharing of records
and information.
(b)
All law enforcement agencies
should develop a collaborative framework
to ensure effective scrutiny at the border.
(c)
Canadian enforcement agencies should engage local border communities to assist in the prevention of illegal
cross-border transfer of firearms, and Canada
should encourage American
law enforcement agencies
to do likewise.
LESSONS LEARNED
Firearms regulations are not enforced in
a consistently effective and accountable manner, leading to gaps and uneven enforcement
within and across jurisdictions.
Current approaches are ineffective partially as a result
of inadequate community engagement, particularly with the gender-based violence advocacy and support
sector and with firearms officers.
EFFECTIVE, CONSISTENT, AND ACCOUNTABLE ENFORCEMENT
OF
FIREARMS REGULATIONS
The Commission
recommends that
(a)
The federal
government should engage with communities, the gender- based violence advocacy
and support sector, and firearms regulatory officers to develop practical guidance policies for the effective, consistent, and accountable enforcement of firearms
regulations.
(b)
The federal
government should engage communities, the gender- based violence advocacy and support sector, and firearms
regulatory officers to develop
a framework for the collection of data about
firearms enforcement.
(c)
The federal
government should collect,
analyze, and report data on enforcement of firearms regulations
publicly.
(d)
The federal
government should immediately ratify and implement the Inter-American Convention Against the Illicit
Manufacturing of and Trafficking in Firearms, Ammunition,
Explosives, and Other Related Materials (CiFTA) and the Protocol Against
the Illicit Manufacturing of and Trafficking in Firearms, Their Parts and Components and
Ammunition (Firearms Protocol).
(e)
The federal
government should fully implement the Programme
of Action to Prevent, Combat
and Eradicate the Illicit Trade
in Small Arms and
Light Weapons
in All Its Aspects (PoA) and the International Instrument to Enable States to Identify
and Trace, in a Timely and Reliable Manner, Illicit Small Arms and Light Weapons
(also known as the United Nations
international Tracing instrument, or iTi).
IMPLEMENTATION POINTS
•
The Ontario
Office of the Chief Coroner’s 2022 inquest into the murders of Carol Culleton, Anastasia
Kuzyk, and Nathalie Warmerdam (the Renfrew County
inquest) made a number of recommendations to improve
enforcement which provide a strong starting point. We endorse that
inquest jury’s recommendation numbers 69–73.
The Chief Firearms
Officer [CFO] should
work with appropriate decision-makers to:
69. Review the mandate
and approach of the CFO’s
Spousal Support line to:
(a)
Change its name to one that better reflects
its purpose. it should
be clear that it is broadly accessible and not limited
to a particular kind of relationship,
(b) Be staffed
24 hours a day and 7 days a week,
(c)
Be publicized to enhance public awareness, and become better known
among policing partners possibly through All Chiefs’ bulletins.
70. Create guidelines for staff in making decisions regarding
whether to issue, review, revoke, or add conditions to PALs [Possession and
Acquisition Licences] to ensure consistency among staff and through time.
Particular attention should be paid to red flags and risk factors around iPv
[intimate partner violence], including where there is no conviction.
71. Require that a PAL is automatically reviewed when someone is charged with an iPv related offence.
72. Require PAL applicants and holders to report to the CFO in a timely manner any change in information
provided in application and renewal forms submitted to the CFO, including when
an individual with weapons restrictions comes to reside in their home.
73. Amend PAL application and renewal forms to require
identification as a surety.
•
Steps should
be taken to promote standardization and quality control measures in data collection by police, as well as mandatory collecting of information by federal, provincial, and local police,
•
This
information should be publicly reporting
on an annual basis.
• information gathered
could include:
◇
disaggregated data on firearm death,
injury and crime
including gender, age, region and other pertinent characteristics;
◇ types of firearms used (unrestricted, restricted (handguns) and others)
and their sources (legal owner, diverted from legal owner, smuggled);
◇ offender/ victim relationship (was the perpetrator known or
unknown to the victim; if the perpetrator was known, what was his or her rela-
tionship to the victim);
◇ firearm ownership and whether the person who used the gun was licensed;
◇ the number of firearms-related investigations, charges and complaints;
◇ a breakdown of the data by gender
of suspect / victim; offence
type; type of firearm;
and demographic indicators such as age, educational
level and income;
◇ the steps and outcome of steps undertaken by police in response to a
firearm related complaint, including the number of firearms removed from individuals following the expiry of a licence; the suspension of
a licence; the revocation of a licence;
and the issuance of an order in
the criminal courts prohibiting an individual
from possessing fire- arms; and
◇
the
outcome of tracing
efforts in each case.
LESSONS LEARNED There
is a lack of community knowledge about the Cana- dian firearms regime. it is
influenced by the United States discourse centred on a right to bear arms which does not exist in our constitutional and legal structure.
This discourse has become increasingly polarized and steps
should be taken to reverse this trend through enhanced community engagement.
There is a lack of community knowledge about the impact of
firearms-related harms. Some community
members do not have accessible, safe mechanisms to report concerns over firearms
ownership, storage and use. Proactive measures are needed to support compliance.
PUBLIC HEALTH APPROACH TO GUN SAFETY
The Commission
recommends that
(a)
The federal,
provincial, and territorial governments should adopt legislation affirming that
gun ownership is a conditional privilege.
(b)
The federal
government should implement a nation-wide comprehensive public education
campaign directed at increasing awareness of existing firearm-related laws and
regulations, options for raising complaints and concerns, and the risks
associated with firearms in the home, including risk factors associated with
accidental injury, suicide, domestic violence, hate crimes, and diversion of
lawfully owned guns.
(c)
The federal
government should establish a national firearms
hotline in consultation with communities, the gender-based violence
advocacy and support sector,
firearms regulations officers, and police services.
(d)
The federal
government should work with the gender-based violence advocacy and support sector and healthcare professional organizations
to develop a framework for the establishment of a duty of care to report concerns about potential violence
and firearms.
(e)
The federal
government should implement
measures that support compliance with firearm storage
laws, including subsidizing storage facilities
in communities where
this is a barrier to compliance.
(f)
indigenous
governments should implement measures to support compliance with firearm storage
laws.
Chapter 14: Police Paraphernalia
LESSONS LEARNED
Police impersonation is a serious public
safety issue, and this outweighs the interests of collectors to own items
of police paraphernalia that can be used as a disguise.
The perpetrator’s use of the replica RCMP cruiser and disguise
during the April 2020 mass casualty has led to a significant increase in public
mistrust of the RCMP and, more generally, the police. Mistrust
of police is itself a public
safety issue.
As a result of the mass casualty, some people, particularly in
the most affected communities, continue to experience fear at the sight of
police cars, particularly RCMP cruisers. Some members of marginalized community
groups, such as those who have been overpoliced and underprotected by police, also experience fear and anxiety when confronted by police
symbols. Policing agencies must work to build trusting and constructive
relationships with the communities they serve.
in some cases, police services
do not appropriately manage the inventory and disposal of police vehicles and any
associated equipment, kit, and clothing, including upon retirement of police
officers.
it is difficult to regulate access to many specific items of police paraphernalia. Comprehensive approaches, such as Nova Scotia’s Police Identity Management Act, are required.
RECORDS OF POLICE IMPERSONATION CASES
The Commission
recommends that
The Canadian criminal
intelligence database be amended to provide for the
sharing and storing of police
impersonation cases and that such cases be tracked in the violent
Crime Linkage Analysis
System database.
MANAGEMENT
AND DISPOSAL OF POLICE
UNIFORM AND ASSOCIATED KIT
The Commission
recommends that
(a)
The RCMP and other
police services should review their policies on the management and disposal of police uniform
and associated kit to ensure they include proactive and effective measures
to manage inventory and disposal including:
(i) a process
for tracking items issued, returned,
and destroyed; and
(ii) a process
for verifying environmentally sound disposal.
(b)
The RCMP and police
services should carry out a quality assurance review of their inventory and
disposal systems within one year of the publication of this Report and on a
triennial basis thereafter.
(c)
The RCMP implement
the recommendations made in the July 2022 audit of the RCMP’s equipment
management processes.
(d)
The RCMP and other
police services should ensure that when police officers retire or otherwise
cease their roles as peace officers, they return all items of police uniform
and kit, including ceremonial uniform and badges.
IMPLEMENTATION POINTS
•
The practice
of issuing veteran
or retired member
badges should cease immediately.
•
Police services
may make arrangements to return badges to members in good standing, after encasing
them in a block of hard plastic of sufficient size to render the badge
unusable.
•
Police services
should issue officers who retire or otherwise cease their work in good standing, after a minimum
period of service,
an appropriate veteran’s blazer,
clearly distinguishable from any police
uniform (ceremonial or general duty) issued to currently working members.
(e)
The RCMP should work with the RCMP veterans
Association to ask retired
members to return items in their personal possession, including badges that have not been encased in plastic and uniforms.
IMPLEMENTATION POINTS
•
Such badges may be
encased in a block of hard plastic of sufficient size to render the badge unusable, and returned to the retired
member.
•
Police agencies
should work with their veterans associations to ensure
that
retired officers in good standing have access to an appropriate
veteran’s blazer, if they wish to have one.
REGULATING
THE PERSONAL POSSESSION OF POLICE PARAPHERNALIA
The Commission recommends that
(a)
The Province
of Nova Scotia
amend the Police Identity
Management Act to remove the exception for personal
possession of ceremonial uniforms.
(b)
Other Canadian
provinces and territories enact legislation equivalent to the Nova Scotia Police
Identity Management Act.
SALE OF DECOMMISSIONED VEHICLES
The Commission
recommends that
(a)
The minister for
public safety should retain a moratorium on the sale of decommissioned RCMP
vehicles to the public until a third-party review of the decommissioning process has been completed, any recommendations
arising from this review have been implemented, and alternative avenues for
disposal (such as transfer to other government agencies or other levels of
government) have been pursued.
(b)
if sales to the
public are resumed, the RCMP should publicly report on an annual basis the number of vehicles
sold and the net revenue raised by such sales.
IMPLEMENTATION POINTS
•
Conscious of the environmental cost of scrapping
vehicles that are in
good condition, we encourage the minister of public safety and the RCMP
to work with GCSurplus to investigate alternative means of retaining roadworthy vehicles
within government fleets,
even when they are no longer suitable for policing.
•
The moratorium on selling RCMP vehicles to the public
should be retained at least until a third-party
review of the decommissioning process has been completed.
GCSURPLUS TRACKING, TRAINING, AND OVERSIGHT
The Commission
recommends that
(a)
GCSurplus and any
company that performs a similar function of disposing of policing assets should develop and implement a policy to identify, track, and report suspicious activity by
buyers and potential buyers.
(b)
GCSurplus and any
company that performs a similar function of disposing of policing assets should
train its warehouse employees to identify suspicious behaviours and follow
this policy and provide management oversight of this role.
Chapter 15: Cultivating Healthy Masculinities
LESSON LEARNED
Promoting healthier masculinities is an
important strategy for improving
community safety and well-being in two ways: preventing gender- based violence,
and improving male health and well-being.
PROMOTING AND SUPPORTING HEALTHY MASCULINITIES
The Commission
recommends that
(a)
The federal
government should develop and implement a national public health education
and awareness campaign to promote healthy
masculinities.
(b)
As part of the National Action
Plan to End Gender-Based violence, the federal government should
support research, evaluation and knowledge exchange about promising practices
to support healthy
masculinities through primary prevention, strategies to intervene
in and respond to
the perpetration of gender-based violence, and to efforts
to promote the recovery and healing of male
perpetrators.
(c)
All Community Safety
and Well-Being Leadership Councils (see Recommendation C.15) should integrate
initiatives to promote
and support healthy
masculinities in primary prevention strategies, in strategies to intervene in
and respond to the perpetration of gender-based violence, and in efforts to
promote the recovery and healing of male perpetrators.
IMPLEMENTATION POINTS
•
All strategies
designed to promote and support healthy masculinities should centre diverse and
intersecting identities, including indigenous cultures and identities and
should take anti-racist, anti-colonization, and anti-oppressive approaches.
•
Following their
appointment, the Gender-Based violence Commissioner should be engaged in developing the federal initiatives (Recommendation v.17).
Chapter 1: Five Principles of Effective Critical Incident Response
LESSON LEARNED
Five strong and consistent principles for effective critical incident response emerge from the literature on critical incident
preparedness and best
practices. When these principles are not followed, critical incident responses
suffer. ineffective critical
incident responses can result in more casualties and cause damage to
community trust in police and other emergency services.
PRINCIPLES OF
EFFECTIVE CRITICAL INCIDENT RESPONSE
The Commission
recommends that
All Canadian police agencies should implement five principles of effective
critical incident response:
1.
Prepare for critical
incidents before they happen, first by acknowledging that they can arise, by
training personnel, and by establishing clear roles and responsibilities for
critical incident response.
2.
Recognize that every
critical incident is unique, and therefore that training and preparation must
equip first responders, communications (911) operators, supervisors, and
commanders to make decisions and act in conditions of considerable uncertainty.
3.
Ensure that planning, policies, and training include
other agencies that will be involved in a critical
incident response, fostering a culture of interoperability among
emergency responders.
4.
Recognize that affected community members are the “true first
responders” to a critical incident, and that they will play a crucial role in
any critical incident response including by providing information to police and
communications operators. Police agencies should engage in clear, timely, and
accurate public communications, including information that will help community
members to protect themselves and others, during a critical incident.
5.
Evaluate every
critical incident response after it takes place, whether the response went well
or not. identify lessons learned, areas for improvement, and practices
that should be emulated. All personnel who are involved
in a critical incident
response should be included in a post-incident evaluation. in turn, these lessons
should be shared in purposeful and coordinated ways to ensure institutional and
public learning.
Chapter 2 Critical
Incident Command and Decision-Making
MAIN FINDING Contrary
to national RCMP policy, in April 2020 the Bible Hill RCMP detachment had no
emergency operational plan in place, and, similarly, H Division had no violent
crime-in-progress emergency operational plan. The
2011 Emergency
Operations Plan: Violent
Crime in Progress
did not reflect
current policies or training and was not in use at the time.
MAIN FINDING H Division
had implemented the MacNeil Report recommendation
to establish an emergency operational plan that identified major transport
routes and critical locations to stop or contain an active threat from moving
across the province. However, those in command of the critical incident
response of April 18 and 19, 2020,
were unaware of the existence of this plan,
and it was not used during
the mass casualty.
EMERGENCY OPERATIONAL PLANS
The Commission
recommends that
The RCMP should ensure emergency operational plans are current
and utilized throughout all divisions.
MAIN FINDING
Acting Cpl. Stuart Beselt was not the
scene commander. Rather, he acted in accordance with RCMP policy by moving
toward an active threat as the leader of an iARD response.
LESSON LEARNED
Police agencies should have clear rules
about the consump- tion of alcohol
and recreational drugs while police officers are on duty. Given the nature of police work, the appropriate standard is to have no alcohol or recreational
drugs in one’s system when on duty.
CONSUMPTION OF ALCOHOL AND RECREATIONAL DRUGS
The Commission
recommends that
The RCMP should
amend its Code of Conduct to
state clearly that members
must have no alcohol or recreational drugs
in their system
while on duty, and that they must not report for
duty or self-deploy if they have consumed alcohol or recreational drugs.
MAIN FINDING We
conclude that S/Sgt. Brian Rehill acted as ad hoc critical incident commander
until S/Sgt. Jeff West assumed control at 1:19 am on April 19, 2020. However,
we find that there was confusion about
the command structure and about who among the RCMP members were performing specific
roles and responsi- bilities in this interim period.
We also find that this confusion detrimentally affected the critical incident
response, most notably with respect to the lack of an assigned on-scene
supervisor to exercise scene command.
LESSON LEARNED
it is essential for responding officers
to know who has
command of a critical incident response. Policies should clearly assign this
role, at all stages of the critical incident response. information about who has
command, and other information about supervisory roles and responsibilities,
should be shared regularly with responding members during a critical incident
response. Other supervisors must refrain from giving directions to responding
members.
SUPERVISION DURING A CRITICAL INCIDENT RESPONSE
The Commission
recommends that
(a)
The RCMP should amend
its policy to identify which non-commissioned officer will attend the scene of
a critical incident response. This person must attend as soon as possible.
(b)
During a critical incident
response, the name and rank of the person who holds command and the name and rank of the scene commander should be recorded in the incident log
and broadcast frequently by radio.
(c)
Supervisors who have
not been tasked with commanding the response should refrain from giving
direction to responding members.
ROLES
AND RESPONSIBILITIES
DURING A CRITICAL INCIDENT RESPONSE
The Commission recommends that
RCMP policies should be amended to make roles and
responsibilities during a critical incident response clearer. in the period
before a critical incident commander assumes command, ad hoc command of the
response should be situated with a suitably
experienced, properly trained,
and appropriately resourced
supervisor within the district command structure.
MAIN FINDING
Risk managers and district supervisors were not adequately trained and had not practised for a large-scale critical incident response. The lack of standardized training, and the overall inadequacy of supervisor training,
contributed to problems within the early critical incident response.
MAIN FINDING Most
supervisors involved in the initial critical incident response on April
18, 2020, had not taken
the mandatory online
initial Critical incident Response (iCiR) 100 training. in any event,
this training is inadequate to equip front- line supervisors with the skills necessary for a large-scale initial critical incident response.
LESSON LEARNED
Front-line supervisors play a critical role throughout a critical
incident response, and they must be adequately trained to perform this role effectively.
FRONT- LINE SUPERVISOR TRAINING
The Commission
recommends that
The RCMP should commission an external expert review of its
initial critical incident response training for front-line supervisors (iCiR
100 and iCiR 200), to be completed
within six months of the publication of this Final Report. This evaluation should be published
on the RCMP’s website.
IMPLEMENTATION POINTS
This review should assess:
•
whether existing
mandatory training adequately equips front-line supervisors to exercise initial
command until an accredited critical incident commander takes command (noting
that present RCMP practice means that it may be several
hours before a critical incident
commander assumes command);
•
the rate of
compliance with mandatory training requirements among front- line supervisors;
•
whether the existing iCiR 200 course adequately equips
front-line supervisors to exercise initial command until an accredited critical
incident commander takes command;
•
the rate of completion of iCiR 200 among front-line
supervisors; and
•
whether iCiR 200 should be mandatory
for front-line supervisors, with or without amendments.
LESSON LEARNED
Critical incident commanders must have
ready access to all of the equipment they need to perform their role.
BASIC COMMAND EQUIPMENT
The Commission
recommends that
Every critical incident commander should have a “ready go duty
bag” with them at all times when they are on call.
This bag should
contain necessary equipment
including police radio, RCMP cellphone, laptop with access to RCMP Computerized integrated information and Dispatch System
and mapping technology, charging
cables, critical incident commander guidebook, and checklists.
LESSON LEARNED Critical incident
decision-making places unique demands
on police and other agencies.
Effective critical incident
decision-making is a skill
that can and should be taught to those who may respond
to a critical incident. it is
particularly important for those in supervisory positions.
TRAINING FOR CRITICAL INCIDENT DECISION- MAKING
The Commission
recommends that
The RCMP and other first-responding agencies should engage
with appropriate experts and training institutions to incorporate “grim
storytelling” and other skills
of critical incident
decision-making into basic
and advanced training for police and communications operators. This training is especially
important for critical incident commanders, risk managers, and front-line
supervisors. These skills should be reinforced in critical incident command and
emergency management courses and practised regularly.
LESSON LEARNED
The highest priority
in a complex critical incident
response is to ensure that the
response reaches the stage, as quickly as possible, where stra- tegic decisions are being made by a fully trained
and experienced critical
incident commander with the tactical
support of properly trained, well-equipped, on-scene, front-line supervisors.
RAPID DEPLOYMENT OF CRITICAL
INCIDENT COMMANDER
The Commission
recommends that
The RCMP should put policies
and standard operating
procedures in place to
ensure that an accredited critical
incident commander with access to all
relevant RCMP systems and infrastructure assumes command of a critical incident
response as soon as possible after a critical incident begins, even if this means that the command post is
physically distant from the critical incident.
IMPLEMENTATION POINTS
•
in H Division, critical
incident commanders should
use the critical
incident operations room in Dartmouth headquarters when this facility
can be most rapidly stood up as a command post.
•
The nearest detachment to the critical incident or another
suitable place should be designated and staffed as a local coordination centre.
Local commanders of other
agencies (e.g., fire chiefs) should
be directed to the
local coordination centre,
and a detachment supervisor should be in place
to ensure that integrated command
and shared situational awareness are
maintained across agencies and locations.
•
Moving to a model of
remote command places even greater importance on the training and preparedness
of front-line supervisors to act as scene commanders and local command.
Districts should ensure that supervisors who are located in detachments are
fully trained to exercise scene command, establish staging areas, establish a
local coordination centre, and liaise effectively with other emergency
responders and the remote critical incident commander.
•
For a prolonged
critical incident response, it may be appropriate for a critical incident
commander to establish a local command post. in this circumstance, a second critical incident commander should be dispatched with
all necessary equipment and support to that location, while the initial
critical incident commander
retains command from the remote command
post.
•
Media and public
communication plans must ensure that the safety of media representatives, media liaison
officers, and public
communications staff is accounted for when local
command locations, staging
areas, and perimeters are
established.
•
The incident
Command System and Emergency Operations Centre models, presently used for integrated response to natural
disasters and similar emergencies, may provide an appropriate model
for this approach.
MAIN FINDING Different
members responded in different ways during the response to the active mobile threat presented by the perpetrator. in
general, though, the overall emphasis on chasing the perpetrator, rather than coordinating
a strategic response to ensure that other necessary tasks were also
completed, impeded the effectiveness of the RCMP’s critical incident
response and, at times,
caused additional harm.
Chapter 3 Information Management During
the Critical Incident Response
LESSON LEARNED
Public safety answering point policies
and procedures should ensure that information obtained via 911 calls or from
responding members is captured, even if its accuracy or significance cannot be
ascertained in the moment. To support this objective, it is important for
communications operators and supervisors to have ready access to 911 call recordings to ensure that all relevant information from a 911 call can
be captured and conveyed to responding members.
CAPTURING INFORMATION FROM 911 CALLS
The Commission
recommends that
All staff at the RCMP Operational Communications Centre and
staff at other public safety answering points should have access to 911 call recordings at their
desk and be trained in how to play calls back.
IMPLEMENTATION POINT
•
Standard operating
procedures should encourage call-takers, supervisors, and risk managers to review calls whenever it may assist them to glean
more
information or review the completeness of the incident activity log.
INCIDENT LOGGING SOFTWARE
The Commission
recommends that
The RCMP should review its incident logging software to ensure
that it allows call-takers and dispatchers to capture all information, and that
standard operating procedures ensure that Operational Communications Centre
staff members are able to capture all relevant information, even for complex incidents. These procedures
should be scalable so that, during a critical incident, communications operators are following the same procedures they follow for more routine calls.
CALL- TAKER TRAINING AND
STANDARD OPERATING PROCEDURES
The Commission
recommends that
(a)
The RCMP and Nova Scotia Emergency
Management Office should review
call-taker recruitment and training to ensure that 911 call-takers are trained to capture
all information shared
by a community member as fully and accurately as possible, and to listen
for background noises
or information that may also
be important for first responders.
(b)
RCMP dispatchers
should be trained and standard operating procedures should require that
information obtained by call-takers be shared using standard language that
signifies the source of the information (e.g., caller says she saw the person
carrying a gun; call-taker heard possible gunshots in the background of the
call). important information should be shared repeatedly, and updates or
conflicting information should routinely be identified.
LESSON LEARNED
911 call-takers play an important role
in our community safety ecosystem. They not only capture and relay information
from 911 callers for first responders, but also play a crucial role in helping
community members to stay safe.
RESPONSIBILITIES TO
911 CALLERS
The Commission
recommends that
(a)
The RCMP Operational Communications Centre training and procedures
should be amended to emphasize
the ethic of care for 911 callers
and the central role played by
911 call-takers in eliciting important information from callers and helping
community members to stay safe and share information even when they are injured
or terrified.
(b)
The RCMP instruction
to call-takers, issued after the April 2020 mass casualty, to end the conversation with callers who can’t see a perpetrator during a critical incident
response should be reversed in favour of a policy that gives equal weight to
strategies for obtaining relevant information about all aspects of a critical
incident including, for example, the location
of injured community members and advising callers about steps that will help
keep them safe.
MAIN FINDING
By 10:30 pm on April 18, 2020, the RCMP had received
information from numerous sources that the perpetrator was driving a replica RCMP cruiser
that, to most observers, would
be indistinguishable from a real RCMP vehicle.
This information should have shaped the command decisions from that time forward.
The failure to recognize that the perpetrator had disguised
himself in this way was a product
of deficiencies in the RCMP’s
process for capturing, sharing, and
analyzing information received during a critical incident response.
LESSON LEARNED
Member
tracking technology, and proper training
in the use of that technology, improves both the effectiveness of a large-scale critical incident
response and public and member safety during the response.
MAIN FINDING Despite
Ret’d. A/Commr. Alphonse MacNeil’s warnings about the importance of being able to track member locations
during a critical
incident, the RCMP failed to implement
the recommendation with respect to geo-tracking Emer- gency Response Team members
in a timely manner. in this regard,
RCMP leadership failed its front-line members
and the public, both of whom would have been better
served in April 2020 if the RCMP had then implemented a recommendation made in
the December 2014 MacNeil Report.
MAIN FINDING
The gap that arose in the RCMP’s efforts
to contain a perimeter east of Portapique and the command group’s failure to recognize that the blueberry
field road provided an alternative route out of Portapique for a
motorized vehicle were not materially caused by any inadequacies in the RCMP’s
mapping technology. H Division was inadequately prepared for a large-scale
critical incident response in a relatively remote area of Nova Scotia. The
uncertainty about roles and responsi- bilities, and the lack of training and
preparedness of front-line supervisors, were the primary reasons for the gaps
that arose in containment.
LESSON LEARNED
Effective radio use is important at all times,
and essential during critical
incident response. Police agencies should
emphasize the importance of following radio protocols, and should have plans in place for managing radio communications during large-scale
incidents.
EFFECTIVE USE OF POLICE RADIOS
The Commission
recommends that
(a) The RCMP should
(i)
commission and publicly share an international evaluation of best practices in radio transmission and incorporate the results of this
evaluation into its training, policies, and practices;
(ii)
conduct a holistic
review of radio training for members, supervisors, and dispatchers, including
the means by which changes in policy, procedure, and equipment are communicated and implemented;
(iii)
prepare plans
for managing radio
communications during large-scale critical incident responses;
(iv)
evaluate radio and uniform design to ensure that the Emergency
Request to Talk (ERTT) button is accessible when it is needed; and
(v)
incorporate radio use and challenges with radio communication into scenario-based and tabletop training.
(b)
RCMP leadership,
supervisors, and Operational Communications Centres should
(i)
emphasize effective
radio use and adherence to proper radio protocols at all times to ensure that good practices are routine; and
(ii)
conduct an annual assessment of division-wide compliance with training and policy.
IMPLEMENTATION POINTS
•
RCMP
radio protocol should
◇ require that the speaker identify
themselves by name,
rank, and role if
relevant; and
◇ identify the intended recipient of the transmission, deliver the
mes- sage, and await confirmation of receipt by the intended recipient.
•
Any upgrades
to radio technology should be accompanied by member- wide
training and practice.
LESSON LEARNED Police
agencies should proactively establish arrangements for air support, including backup plans. Air support providers should be included
in critical incident training.
AIR SUPPORT
The Commission
recommends that
(a)
The RCMP should establish partnerships with other agencies to ensure that air support is available whenever
necessary to a critical incident response.
These agencies should be included in future training and
preparation for critical incident
response to ensure
that they are able to provide the support required.
(b)
The RCMP should adopt a single air support
call-out process, to ensure
that initial critical incident commanders do not waste time and attention
looking for alternative sources of air support.
LESSON LEARNED
During a critical incident response,
many agencies work together to address
the threat and restore safety.
it is essential that these agencies
have a clear and shared understanding of their respective roles and responsibilities, that they have practised
together, and that they can communicate effectively with one another.
INTEROPERABILITY DURING CRITICAL INCIDENT RESPONSE
The Commission
recommends that
(a)
Clear protocols for
unified command posts and agency roles and responsibilities should be
established among all agencies involved in critical incident response.
(b)
All emergency
response agencies in Nova Scotia should be given access to encrypted
radios while responding to a critical
incident, even if these
radios are loaned for the duration of that response. Emergency responders must be given the opportunity to train with these radios
on a regular basis so that they are familiar with their use, when needed.
(c)
interagency scenario-based and tabletop exercises should be incorporated into existing agency
training wherever possible. if this is not possible, agencies should regularly
make time for dedicated interagency training.
Chapter 4 Public Safety
During Critical Incidents
MAIN FINDING
The tweet sent at 11:32 pm on April 18, 2020, was the only informa-
tion
shared publicly by the RCMP until 8:02 am on April 19, 2020. To the extent that the
11:32 pm tweet underplayed the seriousness of the threat to the public, the
RCMP had ample opportunity to correct the public record. it took far too long
to do so.
LESSON LEARNED
Effective public communication during
critical incidents requires clear policies, planning, and training. When police do not communicate effectively, community
members may be unaware of an active threat to their safety and/or
unsure about how to stay safe.
PUBLIC COMMUNICATION DURING CRITICAL INCIDENTS
The Commission
recommends that
(a)
The RCMP should amend
its policies, procedures, and training to reflect the approach recommended in the 2014 MacNeil Report about the
RCMP’s response to the Moncton Mass Casualty; that is, that the RCMP should activate
public communications staff
as part of the critical
incident package.
IMPLEMENTATION POINTS
•
The responsibility to
prioritize and engage public communications staff must be clearly allocated.
•
A public communications officer
should be embedded
within the command post.
•
Effective
implementation of this recommendation requires far more than an email to RCMP
employees.
(b)
The RCMP should train
critical incident commanders and front-line supervisors in their
responsibilities to provide timely and accurate public communications about a
critical incident. This responsibility should be stated within RCMP policies
and procedures.
(c)
The RCMP should fully integrate public communications into its
approach to critical incident response, including training and tabletop
scenarios, and communications officers should train and practise alongside
other members of the command group.
IMPLEMENTATION POINTS
•
Procedures for
approving the timing and content of public communications should be set out in standard operating
procedures and regularly practised.
•
Strategic
communications units should extend their template communications database to
address a wider range of content and potential
scenarios. This database
should be continually updated on the basis of new incidents and insights
from training and practice.
(d)
Consistent with their
legal duty to warn the public, police agencies should disseminate public
information using methods that ensure that public communications reach those
who are most affected by an incident in
a timely manner. When choosing communications strategies, police
agencies should attend to matters of equity and substantive equality, including demographic differences in the use of social media
platforms, as well as the
accessibility of reliable internet and cell service.
IMPLEMENTATION POINTS
•
Effective public
communications may require different strategies in different circumstances, or for different
sectors of the community.
•
When a public
communication is issued about a critical incident or similar event, the
strategic communications unit should conduct a post-incident review of the
timeliness, accuracy, reach, and effectiveness of the public communication.
MAIN FINDING
On April 18 and 19, 2020, key RCMP personnel, including the
command group and risk managers,
did not consider
the option for an emergency broadcast to be sent via the Alert Ready
system until the Nova Scotia
Emergency Management Office contacted the RCMP directly. This failure to
consider issuing an emergency broadcast
reflects a systemic
failure on the part of RCMP H Division,
over several years, to recognize the utility of
Alert Ready for its emergency public communications. This systemic failure
persisted despite individual efforts to draw the
attention of H Division’s leaders
to the opportunities afforded by Alert Ready.
MAIN FINDING The
widespread beliefs that community members will panic and that they cannot be trusted to respond appropriately to information about threats
to their safety are myths. These myths persist despite abundant evidence to the
contrary. These myths have no legitimate place in police decision-making about
whether to issue a public
warning about an active threat
to community safety.
ISSUING PUBLIC WARNINGS
The Commission
recommends that
(a)
When an active threat
to the public exists, police
agencies should share the best available information
about the nature of the threat and how to remain safe with the public as soon as possible. Police agencies should be
prepared to correct or update
information as necessary.
(b)
Police and emergency
services agencies should tailor the means by which public warnings are issued
to the location, scale, and duration of a threat. Police and emergency
services agencies should ensure that public
warnings reach as many community members within an at-risk population
as possible.
TRAINING PERSONNEL TO ISSUE PUBLIC WARNINGS
The Commission
recommends that
The training police
agencies give to critical incident
commanders and risk managers should emphasize the duty
to issue public warnings and equip these personnel with tools to identify when a public warning is necessary and to
decide how best to issue
that warning.
ADDRESSING
MYTHS AND STEREOTYPES ABOUT
COMMUNITY RESPONSES
TO PUBLIC WARNINGS
The Commission
recommends that
The RCMP and the Canadian Police College should incorporate
material that identifies and counters the operation of myths and stereotypes
about community responses to critical incidents into immediate action rapid
deployment training, initial
critical incident response
training, and Canadian Police College training for
critical incident commanders.
NON- URGENT PUBLIC INFORMATION LINE
The Commission
recommends that
The Nova Scotia Emergency Management Office should work with
Nova Scotia police agencies
to establish a phone line and website
that can be used
by community members to report non-urgent information during a critical
incident and to obtain further information about how to respond to a public
warning. information about this facility should become a standard inclusion in
public warnings about critical incidents.
PUBLIC EDUCATION ABOUT PUBLIC WARNINGS
The Commission
recommends that
The Nova Scotia Emergency Management Office and Nova Scotia
police agencies should engage
in a public education campaign,
including in schools, to increase public awareness
about public warnings
and public understanding of how to respond to these
warnings.
Chapter 5 Post-Event
Learning
LESSON LEARNED
Operational debriefs and after-action
reports provide an invaluable means of capturing lessons
learned from a critical incident
response. it is important to include all responding
members in these processes.
OPERATIONAL DEBRIEF AND AFTER- ACTION REPORT
The Commission
recommends that
The RCMP should implement policies and procedures to require an operational
debrief and after-action report for any critical incident response that
required the active engagement of a critical incident commander.
IMPLEMENTATION POINTS
The policies
and procedures should
include the following:
•
The commanding
officer of the division will direct in writing that the operational debrief
process is engaged
and assign a commissioned officer to oversee the completion of an operational debriefing and to prepare an after-action report.
•
A supervisor who possesses the skills and training to conduct operational debriefings will be assigned
to facilitate these sessions, and the debriefing will include all employees
who played a part in a critical
incident response.
•
A written summary of
the operational debrief must be submitted by the assigned supervisor of the
operational debrief to the commissioned officer who has been appointed to
oversee this process and produce the after- action report.
•
A comprehensive after-action report should
be produced by the assigned commissioned officer. This
after-action report should highlight any risk areas for immediate action.
•
The after-action report
should be submitted to the commanding officer within 30 days of the event occurring. in the event that
the 30-day timeline is not met,
approval in writing is required by the commanding officer with a stated due
date.
•
The commanding
officer should address any risk areas identified in the after-action report
for immediate action,
including any updates
to relevant policy,
procedures, and training, as soon as practicable. Reporting on implementation
of these items should be a standing item on monthly bilateral meetings so that
progress can be monitored and roadblocks addressed.
•
The after-action report and a written response
from the commanding officer should be shared within
60 days of the critical incident with every employee who participated in the critical
incident response, with the
RCMP Operational Readiness
and Response Unit, and with the deputy commissioner of contract and indigenous policing
for their situational awareness and institutional
review.
•
Where the commanding officer
or deputy commissioner of contract and indigenous policing identifies the
need for an after-action review, that review should be commissioned within 90
days of the critical incident. A copy of the after-action report and written
summary of the operational debriefing should be shared with the independent
reviewer.
PUBLIC REPORTING ON CRITICAL INCIDENT RESPONSE
The Commission
recommends that
The RCMP should
prepare and publish
an annual report
that explains what the
RCMP has learned
from operational debriefings and what changes
it has made in response to after-action reports
in the previous year. This report
should provide an amount of tactical and operational information similar
to that provided by other agencies; for
example, ALERRT (Advanced Law Enforcement Rapid Response
Training) Center reports
and (US) National Policing institute reports such
as the Orlando Pulse nightclub report.
AFTER- ACTION REVIEW OF MASS CASUALTY INCIDENTS
The Commission
recommends that
Within 90 days of a mass casualty incident occurring, the RCMP
should initiate an after-action review to be conducted by an arm’s length
reviewer.
IMPLEMENTATION POINTS
•
This review should be
commissioned by the deputy commissioner of contract and indigenous policing
and should supplement, not replace, the process set out for operational
debriefings and after-action reports.
•
The after-action
review should be completed and published within six months of being commissioned. if this deadline
cannot be met, the RCMP should provide a detailed public
rationale.
•
After-action reviews
should provide a similar amount of tactical
and operational information to that provided by agencies in other
jurisdictions; for example, in ALERRT (Advanced Law Enforcement Rapid
Response Training) Center reports and (US) National Policing institute
reports such as the Orlando Pulse nightclub report.
Chapter 6 RCMP Public
Communications and Internal Relations After the Mass Casualty
MAIN FINDING RCMP
communications personnel and leaders did not have effective standard operating
procedures or policy to guide them in their public communications or to
delineate the respective roles of national headquarters and divisional
personnel after the mass casualty.
LESSON LEARNED Police agencies
have an obligation to provide timely,
accurate, and candid information about their work to the public.
PUBLIC COMMUNICATIONS AFTER A CRITICAL
INCIDENT
The Commission
recommends that
(a)
The RCMP’s national
communications policies should be revised to state clearly that the objective
of the RCMP’s public communications is to provide accurate
information about the RCMP’s operations, and in
particular to respond
to media questions
in a timely and complete
manner. This principle should be limited only by legal restrictions
(e.g., privacy laws) and the minimum withholding necessary to protect
the integrity of ongoing investigations.
IMPLEMENTATION POINTS
•
RCMP employees should work toward
the goal of sharing as much
information as possible and as quickly as possible.
•
Where information is withheld to protect the integrity of an ongoing
investigation,
that information must be publicly
shared as soon as
investigative needs no longer apply.
•
Where inaccurate information is provided, a public correction must be issued as
soon as the error is identified.
(b)
RCMP policy and
guidance should be amended to require personnel in national headquarters to
assist divisional personnel with the operational and communications demands that arise after
a complex critical
incident or an emergency of similar scale.
IMPLEMENTATION POINTS
•
When an incident has
had a significant impact on divisional personnel or goes beyond the normal
operations of the division, standard operating procedures should provide for
additional resources to be assigned immediately to permit accurate
and timely information to be conveyed
to the public and to support internal briefing.
•
National headquarters staff should respect pre-established
reporting structures when seeking information from and issuing directions to
divisional staff.
(c)
The draft “RCMP
Crisis Communications Reference Guide and Standard Operating Procedures” should
be revised to reflect the findings and recommendations of this Report and it
should be reviewed annually thereafter. This document should form the basis for
mandatory training for RCMP
communications personnel and officers who perform a public- facing role as
spokesperson or liaison officer. These personnel should be required to review
the guide regularly, and their performance should be evaluated in part by their demonstrated compliance with policy
and with the principles set
out in the guide.
Chapter 7 Issues
Management and Interagency Conflict
in the Post-Crisis Period
MAIN FINDING There were several barriers
to an effective interagency review of
gaps in information sharing and co-ordination in relation to the 2011 Criminal
intelligence Service NS bulletin about the perpetrator. One of
those barriers is that the RCMP’s issues Management Team assigned to address
the bulletin was not focused on examining it with a view to institutional learning, and there was no other team within the RCMP carrying out that work. A second barrier was the interagency conflict and distrust that
prevented involved police agencies from working
co-operatively
to examine lessons
learned arising from the bulletin. A third was the
position taken by the RCMP that the bulletin should
not be proactively disclosed to the public, which further elevated the
mistrust of municipal police leaders.
The RCMP’s failure to grapple with the implications
of the 2011 Criminal intel- ligence Service NS bulletin represented another missed opportunity to learn the lessons that emerged from the mass casualty.
The RCMP’s decision not to
proactively disclose information about the bulletin was not
taken for investigative reasons, and this decision increased public and peer
mistrust of the organization. The collective failure
of Nova Scotia police leaders,
including H Division
officers, to constructively address the conflict that arose among them
in the aftermath of the mass casualty only exacerbated these concerns.
LESSON LEARNED
An incident such as a mass casualty
should prompt good faith collaboration by police agencies to examine whether
gaps in interagency informa-
tion sharing or coordination affected prior police responses to the
perpetrator.
Chapter 8 Involvement of the Serious Incident Response Team in
the Post-Crisis Period
MAIN FINDING in
the particular circumstances of the investigation at the Enfield Big Stop, in
which specialized forensic investigation services were available from the RCMP
and from Halifax Regional Police, the Serious incident Response Team should have taken immediate
steps to ascertain
which police agency’s
members were involved in shooting the
perpetrator, and engaged the forensic identification services of the
other agency.
LESSON LEARNED The Serious incident
Response Team performs
a crucial role in
safeguarding public trust in the police and the overall
fairness of the Nova Scotia criminal justice system. it is
imperative that their work be – and be seen by the public to be – independent
of the police agencies whose members they investigate.
SERIOUS
INCIDENT RESPONSE TEAM INVESTIGATORS AND
SPECIALIZED SERVICES
The Commission
recommends that
Whenever feasible, the Serious incident
Response Team (SiRT)
should perform its work using investigators and specialized services
from an agency
separate from the one that employs
the officer who is the subject of the investigation.
if this is not feasible, the decision to use investigators or
specialized services from the police agency that employs the subject officer
should be made by the SiRT’s civilian director. in writing, and at the time when the decision
is made, the SiRT director should document the reasons why using resources
from the agency that employs the subject officer
is necessary.
LESSON
LEARNED The Serious incident
Response Team should maintain control over crime scenes and evidence that
pertains to its investigations. When a police
agency requires access to a crime scene or evidence controlled by the SiRT, that access should be managed by the SiRT.
SERIOUS
INCIDENT RESPONSE TEAM CONTROL OF CRIME SCENES AND
EVIDENCE
The Commission recommends that
(a)
The Police Act and Serious Incident Response Team Regulations be amended to clarify
that
(i)
the SiRT has exclusive
control over investigations of serious incidents involving police; and
(ii)
when the SiRT assumes
responsibility for an investigation, the SiRT will immediately assume command
of all activities related to the
scene, exhibits, investigation, and direction of resources.
(b)
Where a police
agency, including the RCMP, requires access to a crime scene or exhibit in order to pursue a parallel criminal
investigation, that access should
be managed in accordance with protocols set by the SiRT.
(c)
RCMP H Division
Operational Manual Chapter 54.1 should be amended to reflect the Police Act and Serious
Incident Response Team Regulations, including the above principles.
MAIN FINDING
After
the Onslow fire hall shooting,
the RCMP failed to adhere to
its policies and the Serious Incident
Response Team Regulations with respect to the
procedures that must be followed
after a serious
incident that attracts
SiRT jurisdiction.
LESSON LEARNED it
is important for police officers and their supervisors to know what to do when a serious
incident that may attract Serious
incident Response
Team jurisdiction occurs, and it is important that the Serious Incident Response Team Regulations be
observed.
KNOWING
WHAT TO DO WHEN SERIOUS
INCIDENT RESPONSE TEAM JURISDICTION ARISES
The Commission
recommends that
(a)
RCMP members in
supervisory positions should know what steps they must take when a member
discharges a firearm or is otherwise involved in a serious incident that
attracts Serious incident Response Team jurisdiction. This includes knowing:
(i) who is responsible for reporting a serious incident;
(ii) how to make such a report;
(iii) the timeline
on which such a report must be made;
(iv)
what information the
reporting officer must obtain and provide to SiRT about the incident;
and
(v)
to separate involved
members (both witnesses and subject members) immediately after a serious
incident occurs.
(b)
Any failure to follow
these procedures should be documented in writing by the RCMP, and a copy of
that document should be provided to the SiRT.
(c)
The RCMP should
ensure that H Division members receive training in applicable legislation, RCMP policy, and their obligations and rights with regard to SiRT investigations. This instruction should
be incorporated into annual use of force / incident
response requalification training.
(d)
Supervisory training
courses and annual use of force / incident response curriculum should include
instruction on legislation, RCMP policy, members’ obligations and rights,
and requirements of supervisors with regard to SiRT investigations.
LESSON LEARNED
individuals who are affected by serious
incidents involving the police are entitled to receive updates about a SiRT
investigation and may require victim support services.
PROVIDING SUPPORT TO SERIOUS INCIDENT RESPONSE TEAM WITNESSES
The Commission
recommends that
The Serious incident Response Team establish or revise its
procedures to ensure that witnesses
and other individuals affected by serious
incidents involving the police are provided with updates about the
progress of the SiRT investigation and are referred to available support
services.
MAIN FINDING The minimum content
provided in section
9 of the Serious Incident
Response Team Regulations for public
reports issued by the SiRT is inadequate to discharge the public accountability function performed by
the SiRT. Staffing and budget
constrain the SiRT’s capacity to provide more detailed public reports than it presently
supplies.
LESSON LEARNED Communications
between the Serious incident Response Team and the police agency that employs
an officer who is subject to a SiRT investi-
gation should be kept to a minimum, and should only be carried out by a
designated liaison within the subject police
agency. An officer
who is the subject of a SiRT investigation should not communicate directly with the SiRT investigator (outside of providing evidence
or information to the SiRT)
during ongoing investigations.
RCMP LIAISON WITH THE SERIOUS INCIDENT RESPONSE TEAM
The Commission
recommends that
(a)
RCMP H Division
policy should be amended to provide that all RCMP communications and
coordination with the Serious incident Response Team regarding an ongoing investigation must occur through
a designated RCMP liaison,
who must be a commissioned officer and trained in the responsibilities and expectations of this role.
The SiRT should
also implement a corresponding policy requiring its investigators not to
communicate about ongoing SiRT investigations with members of the subject
police agency besides that agency’s designated liaison person.
(b)
The only purpose for which any other RCMP member may communicate
directly with SiRT about an ongoing investigation is when giving a statement
or witness interview, which must be coordinated through the RCMP
Liaison Officer.
MAIN FINDING
Representatives of the Serious
incident Response Team and the RCMP met with one another to exchange information before the SiRT had issued its decision
in the Onslow fire hall shooting referral. Their decision to meet reflects a misunderstanding on the part of both the SiRT and the RCMP about their respective obligations to protect the SiRT’s independence as a law enforcement
and public accountability body.
MAIN FINDING
Evidence raising concerns about the
reliability of the expert use of force report commissioned by the SiRT in this
instance raises questions about the effectiveness of the SiRT’s approach to
identifying, retaining, and instructing experts and the role of such experts in
its decision-making process.
SERIOUS
INCIDENT RESPONSE TEAM PROTOCOL FOR
INFORMATION EXCHANGE WITH POLICE
AGENCIES
The Commission
recommends that
(a)
The Serious
incident Response Team should adopt a protocol
that it will not meet with members of the police
agency that employs
a subject officer to exchange information about an ongoing investigation.
(b)
The SiRT should also
adopt a protocol that sets out how information will be exchanged when two
agencies are engaged in parallel criminal investigations. Any such exchange of
information must occur in writing.
(c)
While a SiRT
investigation is ongoing, the SiRT should not share information with the agency that employs
the subject police officer(s)
for the purposes of an internal investigation conducted by that agency,
including internal conduct
or workplace investigations.
LESSON LEARNED it is important that the Serious
incident Response Team retain
experts who are independent and able to provide an expert opinion that will
meet Canadian legal standards for expert witnesses.
EXPERT WITNESS RETAINED BY
THE SERIOUS INCIDENT RESPONSE TEAM
The Commission
recommends that
The Serious incident Response Team should adopt written protocols for the
identification
and retention of experts in its investigations. These protocols
should reflect Canadian legal principles with respect to the reliability and independence of expert witnesses.
MAIN FINDING Concerns
about the impact of an investigation on interagency relationships must never be a basis on which the Serious
incident Response Team declines to exercise its law enforcement
powers.
LESSON LEARNED
Agencies that investigate alleged
criminal wrongdoing by police
officers provide a critical law enforcement and public accountability function.
They must be adequately resourced and trained to allow them to do their work
thoroughly and effectively.
SERIOUS INCIDENT RESPONSE TEAM RESOURCES
The Commission
recommends that
The Province of Nova Scotia should undertake a review of the Serious incident Response Team’s budget and staffing complement to ensure it can fully exercise
its investigative responsibilities and perform its public accountability function and maximize its contribution to enhanced confidence in policing in Nova Scotia.
SERIOUS INCIDENT RESPONSE TEAM REPORTS
The Commission
recommends that
(a)
Section 9 of the SiRT Regulations should be amended to
adopt the language set out in section 34 of the Ontario Special Investigations Unit Act.
This amendment will ensure that the SiRT’s public reports in instances
where no charges are laid provide sufficient information to allow
the public to understand why
SiRT has reached its conclusion and to evaluate that outcome.
(b)
Starting immediately, all SiRT reports in which criminal charges are not laid against the subject police
officer should be drafted with sufficient detail and analytical transparency to allow the public to understand and evaluate
the director’s reasoning and conclusions.
Chapter 9 What Are the Police For?
LESSON LEARNED Police
agencies should be democratically accountable, attuned to good evidence
about effective practice,
and oriented to articulating
and serving the common good. They should combine law enforcement with collaborative work to prevent harm and promote and maintain community safety.
They should listen to the demands of all citizens,
while directing resources
toward meeting the needs of the most marginalized members of our
communities. They should be subject to strong forms of government and citizen
oversight and accountability.
PRINCIPLES OF POLICING
The Commission
recommends that
All levels of government and Canadian police agencies adopt the
following principles of policing,
as framed by Dr. ian Loader, “in Search of Civic Policing: Recasting the ‘Peelian’
Principles” (2016):
1.
The basic mission of
the police is to improve public safety and well- being by promoting measures
to prevent crime,
harm and disorder.
2.
The police must
undertake their basic mission with the approval of, and in collaboration with,
the public and other agencies.
3.
The police
must seek to carry out their tasks
in ways that contribute
to social cohesion and solidarity.
4.
The police
must treat all those with whom they come into contact
with fairness and respect.
5.
The police
must be answerable to law and democratically responsive to the people they serve.
6.
The police must be organized
to achieve the optimal balance between effectiveness,
cost-efficiency, accountability and responsiveness.
7.
All
police work should
be informed by the best available evidence.
8.
Policing is undertaken by multiple providers, but it should remain a public
good.
These principles should govern how police do their work and how
they are accountable for the work they do.
Chapter 10 A Future
for the RCMP
LESSON LEARNED Police
agencies and police officers must be capable of acknowledging and taking
responsibility for their mistakes.
TAKING RESPONSIBILITY
The Commission
recommends that
(a)
The RCMP adopt a policy of admitting its mistakes, accepting responsibility for them, and
ensuring that accountability mechanisms are in
place for addressing its errors. This policy should
apply at every
level of the institution.
(b)
The demonstrated
capacity to accept responsibility for one’s errors should be a criterion for any promotion
within the RCMP.
LESSON LEARNED The minister responsible for the RCMP serves an important democratic accountability function. The minister
can and should issue written directions to the RCMP about policy matters, including
the policy of operations. it is also necessary
for the minister and the commissioner to exchange information,
including information about specific investigations or police operations, to allow the minister
to discharge their
democratic role. However,
the minister must not
direct the RCMP about how it pursues
particular investigations. Both the minister and the RCMP should be publicly
accountable for the ways in which they discharge their responsibilities.
MINISTERIAL DIRECTIONS TO THE RCMP COMMISSIONER
The Commission
recommends that
(a) Federal Parliament should amend section
5(1) of the RCMP Act to
provide:
The Governor in Council may appoint an officer, to be known as the Commissioner of the Royal Canadian Mounted Police, to hold office during pleasure, who, subject to this Act and any written
directions of the Minister, is responsible for the control and administration of the Force.
(b) The RCMP Act be further
amended to include
the following provisions:
(a)
The Minister must
cause a copy of any such written direction given to the Commissioner to be:
(i)
published in the Canada Gazette
within eight days of the date
of the direction; and
(ii)
laid before
the Senate and the House
of Commons within
six sitting days of the direction if Parliament is then in session, or, if
not, within six sitting days after the commencement of the next session of
Parliament.
(b)
No Ministerial
direction may be given to the Commissioner in relation to the appointment, transfer,
remuneration, discipline, or termination of a particular person.
POLICIES
GOVERNING THE ROLES AND RESPONSIBILITIES
OF
THE RCMP
AND MINISTER OF PUBLIC SAFETY
The Commission
recommends that
(a)
The RCMP and the
minister of public safety should adopt complementary written policies that set
out their respective roles, responsibilities, and mutual expectations in police
/ government relations. These policies should
adopt the principles and findings on police / government relations outlined in Chapter 10 of volume
5, Policing, of this Report,
including specific provisions on the following issues:
(i) police operational responsibilities;
(ii) government policy responsibilities;
(iii) policy of operations; and
(iv) information exchanges between the RCMP and the government.
(b)
These policies should
be posted on the RCMP and the Public Safety Canada websites.
PROTECTING POLICE OPERATIONS
The Commission
recommends that
The RCMP should establish policies
and procedures to protect incident commanders, investigators, and
front-line members from exposure to direct government intervention or advice.
LESSON LEARNED
The work of the Management Advisory
Board for the RCMP should adhere to the principles of transparency and
democratic accountability that otherwise apply to the police.
ADVICE OF THE MANAGEMENT ADVISORY BOARD
The Commission
recommends that
(a)
Federal Parliament
should amend Section 45.18(3) of the RCMP
Act to provide that:
The Management Advisory Board must provide the Minister with a copy or a summary of any advice, information, or report that it
provides to the Commissioner, within eight
days of providing that advice.
(b)
Federal Parliament should add a new subsection, 45.18(4), to the RCMP Act to provide that:
The Minister must cause a copy of any document
provided by the Management Advisory Board pursuant to
section 45.18(3) to be:
(a) published on the website
of Public Safety Canada; and
(b)
laid before
the Senate and the House
of Commons within
six sitting days of the direction if Parliament is then in session, or, if
not, within six sitting days after the commencement of the next session of
Parliament.
LESSON LEARNED Conducting
investigations into public complaints against police officers is a specialized skill. Police agencies
should ensure that such inves- tigations are conducted by
personnel who are properly trained in conducting such investigations and who do
not have a real or perceived conflict of interest.
INTERNAL INVESTIGATION OF PUBLIC COMPLAINTS
The Commission
recommends that
(a)
The RCMP allocate sufficient resources to the RCMP Professional Responsibility Unit to ensure
that it has the capacity
to conduct investigations
into public complaints.
(b)
The RCMP should not
assign public complaints to the direct supervisor of a member who is the
subject of a public complaint or to investigators within the same program as a
subject member.
CIVILIAN REVIEW AND COMPLAINTS COMMISSION PROCESS
The Commission
recommends that
(a) Federal Parliament amend the RCMP Act to specify:
(i)
timelines for the
RCMP commissioner to conduct an initial investigation and attempt to resolve public complaints, and to
respond to CRCC interim reports; and
(ii)
a requirement for the
RCMP to publicly report annually on the implementation of CRCC recommendations.
(b)
The federal minister
for public safety issue a written direction to the commissioner of the RCMP to prioritize the timely investigation of public complaints at the initial
stage of the CRCC process
and to work to resolve these complaints where possible
at the initial stage.
LESSON LEARNED
Agencies that investigate public
complaints against police agencies must be adequately funded to perform
their work fully and effectively. Failure to provide adequate
funding risks impairing
the independence of these
agencies.
CIVILIAN
REVIEW AND COMPLAINTS COMMISSION FUNDING AND
POWERS
The Commission
recommends that
(a)
The Government of Canada should ensure that the Civilian Review and Complaints Commission has sufficient
stable funding to fulfill its mandate. in particular, in addition to reviewing public complaints, it must be able
to conduct systemic
investigations and public
interest investigations as it deems necessary, and to explore
alternative complaint resolution
mechanisms, such as indigenous legal approaches to dispute resolution.
(b)
The minister for
public safety issue a written direction to the RCMP commissioner that RCMP employees
should support efforts by the Civilian
Review and Complaints Commission to explore
alternative complaint
resolution mechanisms.
LESSON LEARNED
Provincial and municipal officials have
authority to ensure greater community involvement in RCMP decisions about
staffing.
COMMUNITY INVO LVEMENT IN SENIOR RECRUITMENT
The Commission
recommends that
(a)
Provincial ministers
and municipal chief administrative officers should discharge their
responsibility under the Provincial Police Services
Agreement and the Municipal Police Services Agreement
to ensure that they and the community are consulted
on the selection of detachment commanders.
(b)
The RCMP should
facilitate this consultation by ensuring that the provincial minister or the
municipal chief officer (as applicable) receives timely notice of a pending change
in detachment commander.
LESSON LEARNED
Past inquiries and reviews have
documented problems in the structure of RCMP contract policing, particularly regarding clarity
in the respective roles and responsibilities of contract partners,
national RCMP headquarters and RCMP contract divisions. Past recommendations have not been fully implemented, and problems identified in
past processes persist today.
IMPLEMENTING
THE 2007 BROWN TASK FORCE RECOMMENDATIONS
The Commission
recommends that
The RCMP implement the following recommendations that were made by the Brown Task Force in 2007:
Recommendation 41 – Delegation
of Decision Making with Respect to Contract Policing The RCMP should examine and review its approval authorities to
ensure that those closest to operational police activity have the requisite
authority to make decisions in a timely manner.
Recommendation 42 – Contract
Partner Participation Headquarters should give greater weight to the views and
priorities of contracting authorities and should involve them in a more
meaningful way in decisions that have an impact on their jurisdictions.
Recommendation 44 – Roles and
Responsibilities of Headquarters The RCMP should develop a written mandate defining the roles and
responsibilities of headquarters and its relationship with its divisions.
LESSON LEARNED
Longstanding issues with soft vacancies
and challenges with recruitment mean that contracting provinces and territories
do not receive the active service of the number
of RCMP members
for which they have contracted.
ADDRESSING CONCERNS ABOUT POSITION VACANCIES
The Commission
recommends that
The RCMP should adopt a system that ensures
that contracting provinces and territories receive the active service of the
number of members for which they have contracted. The RCMP should
ensure that temporary vacancies are filled to ensure that appropriate
coverage is provided in contract jurisdictions.
LESSON LEARNED
Front-line supervisors play a vital role
in policing. it is import- ant that front-line supervisors be available to provide field supervision to general
duty members and to provide scene command when needed.
ENSURING ADEQUATE FIELD SUPERVISION
The Commission
recommends that
The RCMP should
ensure that general
duty members in rural areas
have adequate field supervision and that trained
supervisors are available to provide scene command when needed. in smaller districts or
detachments, this supervision may be achieved through an on-call rotation for
corporals and sergeants. Risk managers, who provide remote supervision, do not
fulfill this requirement.
LESSON LEARNED
Past inquiries and reviews have called
for a comprehensive review of the RCMP. These
recommendations have not been implemented.
A COMPREHENSIVE EXTERNAL REVIEW OF THE RCMP
The Commission
recommends that
The federal minister
of public safety commission the in-depth, external,
and independent review of the RCMP recommended by Mr. Bastarache in his 2020 report Broken Dreams, Broken Lives. in addition to examining the matters
raised by Mr. Bastarache, this review should
specifically examine the RCMP’s
approach to contract policing and work with contract partners, and also its approach
to community relations.
RESTRUCTURING THE RCMP
The Commission
recommends that
After obtaining the external review
recommended here, Public
Safety Canada and the federal minister
of public safety
establish clear priorities for the RCMP, retaining the tasks that are suitable
to a federal policing agency,
and identifying what responsibilities are better reassigned to other agencies
(including, potentially to new policing agencies). This may entail a
reconfiguration of policing in Canada and a new approach to federal financial support for provincial and municipal
policing services.
MAIN FINDING
There is a long history of efforts to
reform the RCMP’s contract policing services model
to be more responsive to the needs
of contracting partners and the communities they
represent. These efforts have largely failed to resolve long-standing
criticisms of the extent to which the RCMP attends to the particular needs and
priorities of contract partners or addresses their expressed concerns.
LESSON LEARNED
Policies and procedures provide
essential guidance to police about how to do their work. They should be clear, concise,
and easily used. Police
policies should be public and readily available to the public,
as a principle of democratic
accountability and to help the public know what they can expect when dealing
with police.
REWRITE AND PUBLISH RCMP POLICIES
The Commission
recommends that
(a)
The RCMP should adopt
a systematic approach
to policies, procedures, plans, and other guidance
materials for its Contract and indigenous Policing business line:
(i)
Existing policies
should be rewritten to provide concise,
evidence- based, meaningful guidance to RCMP members and employees about core functions.
(ii)
Policies and other guidance
documents should reflect
– and refer to – Canadian legal principles that guide the
exercise of police powers. Gaps and duplication within policies should be
eliminated.
(iii)
An institutional
process of reviewing policies and guidance documents when training or
institutional practice changes should become
routine.
(b)
The RCMP should post
on its public website, as soon as feasible and on an ongoing basis, up-to-date copies of those policies and standard operating procedures that govern the
interaction of police with the public, the manner in which policing services
are provided to the public, and public communications.
(c)
Where a policy or
procedure or a portion of a policy or procedure is deemed confidential, the RCMP should
post a public description of each
exempted section and the reason
why it has been deemed
confidential.
ROLE
OF
RCMP CONTRACT PARTNERS AND DIVISIONS IN POLICY
The Commission
recommends that
(a)
The RCMP should
consult contract partners before and throughout the amendment or adoption of
policies that affect the delivery of policing services in contract
jurisdictions.
(b)
RCMP divisions and
detachments should be afforded sufficient resources and discretion under
policy:
(i)
to consult with
contract partners and community representatives about how RCMP policy will be interpreted; and
(ii)
to create
operational plans, standard
operating procedures, and other
guidance documents, in consultation with contract partners, that reflect community
resources, local policing objectives, and priorities.
LESSON LEARNED
Canadian communities must be able to
depend on a timely response to a call for police assistance. While the possibility of immediate response, and the nature of the response, may vary with the geographic context and the nature of the complaint, maintaining
the unique responsibilities of police under
the rule of law necessitates that adequate police services be provided in rural and
remote communities.
ADEQUATE POLICE SERVICES
IN RURAL AND REMOTE COMMUNITIES
The Commission
recommends that
Where necessary, provincial, territorial, and federal
governments must provide financial support to municipalities and local communities including indigenous
communities for the provision of adequate policing services
within rural and remote communities.
LESSON LEARNED Rural
policing is challenging work that requires a distinctive skillset. These skills
should be recognized, cultivated, and rewarded, and rural police should have access to meaningful career progression opportunities within rural policing.
REVITALIZING RURAL POLICING
The Commission
recommends that
(a)
The RCMP should
establish an attractive career stream for members who wish to develop a specialization in rural or remote policing:
(i)
members should have the opportunity to remain in communities
where they are serving effectively and where the community supports their
continuation, while progressing within their careers; and
(ii)
potential leaders
should also be given the opportunity to pursue
further training, including higher education, on matters of particular relevance
to rural policing.
(b)
The RCMP should ensure that members
with current operational experience and expertise in rural and remote communities are represented at all levels of decision-making within RCMP Contract
and indigenous Policing.
COMMUNITY ORIENTATION FOR NEW MEMBERS
The Commission
recommends that
(a)
Every rural and
remote detachment should work with its local community to prepare
an orientation program
for members who are new to the district.
IMPLEMENTATION POINTS
•
All members
transferred into a new district
or detachment should complete this orientation program
within six months
of their assignment.
•
When possible, this
orientation program should include an introduction to other community
safety providers such as healthcare providers and women’s shelters.
•
Whether such meetings
are possible or not, new members should receive a package containing details
about local service providers, the services they offer, and how they can be contacted when needed.
(b)
The RCMP should also establish national
standards for the institutional
orientation that must be given to any member who transfers between divisions or
districts.
IMPLEMENTATION POINTS
These national
standards should address:
•
completing the local orientation program;
•
reviewing policies
and standard operating
procedures relevant to the
member’s area of responsibility;
•
understanding local command structure, roles, and responsibilities;
•
completing training
with respect to local or divisional resources (such as radio and communications
systems) and local culture and history (such
as training programs that relate specifically to local indigenous or
African Nova Scotian communities);
•
reviewing applicable legislation and bylaws including, for example, rules relating to matrimonial property
on indigenous reserves; and
•
acquiring a knowledge of the local geography – for example,
by attending calls and
community events across the area served by that detachment.
MAIN FINDING
The Depot model
of police training
is inadequate to prepare RCMP members for the complex
demands of contemporary policing, and the RCMP’s
failure to embrace a research-based approach to program development and police education and its lack of openness
to independent research
impairs its operational effectiveness.
LESSON LEARNED
The existing Canadian standard of police
training outside Quebec is inadequate to equip police for the important work they do and for the increasingly complex
social, legal and technological environment in which they work. The shortcomings produced by
this approach have a disproportionate adverse
impact on those
who have historically been underserved by police.
MODERNIZING POLICE EDUCATION AND RESEARCH
The Commission
recommends that
(a)
The RCMP phase out
the Depot model of RCMP training by 2032 and the RCMP consult with the Métis
and Saskatchewan Federation of Sovereign indigenous Nations with respect to how
the land and the facility should be used in the future.
(b)
Public Safety Canada work with provinces
and territories to establish a three-year degree-based model of police education
for all police services in Canada.
IMPLEMENTATION POINTS
•
implementing police
education programs may entail partnering with existing institutions of higher
education, and will require collaboration between ministries of higher education and research and federal,
provincial, and territorial ministers responsible for policing.
•
The new model of
police education should be research-based, allow students the opportunity to participate in research, and lead candidates to a three-year bachelor’s degree in policing.
•
Attention should be
paid to ensuring that the new model is accessible and culturally responsive to
women, indigenous students, and other groups
that have historically been underrepresented in and underserved by police in Canada.
Offering financial support to qualified candidates from these groups may help
to attract a more diverse group of policing students.
The new police
education model should
adhere to national
standards, but it should
be offered on several campuses
in different Canadian
regions.
These campuses will likely be affiliated with existing universities or colleges.
•
ideally, at least one campus should be established in the Atlantic
region and one in northern Canada.
•
Public Safety
Canada should consult
with the Finnish
Police University College and Finnish Police in the design of this program.
(c)
Public Safety Canada
and the RCMP should integrate the Canadian Police College into the new police
university system subject to the same governance as other institutions in that
system.
(d)
Responsible ministers
and police boards should issue written directions to police services to collaborate with universities on research
and programming and in the development of evidence-based policies and procedures.
USE OF FORCE
The Commission
recommends that
The Government of Canada and the RCMP should replace
the existing use of
force provision in the RCMP Code of Conduct
with the principles set out in sections 2 to 9 of the Finnish Police Act.
LESSON LEARNED Conflict management is an essential
skill for all police officers, but especially for supervisors and managers.
CONFLICT RESOLUTION SKILLS
The Commission
recommends that
(a)
The RCMP make in-person
conflict resolution training
mandatory for all RCMP
members before promotion to the rank of staff
sergeant or above, and before promotion to an equivalent civilian position.
IMPLEMENTATION POINT
•
The RCMP should
contract with an external training provider that has an established track
record in delivering effective conflict resolution training until such time as
a culture of conflict resolution becomes engrained and its internal capacity to
deliver effective internal conflict resolution training is established.
(b)
The RCMP make demonstrated conflict resolution skills a criterion
for promotion to all RCMP leadership positions.
MAIN FINDING Some aspects
of the RCMP’s management culture
impede its operational effectiveness and thwart institutional learning and accountability. Unhealthy patterns
include:
• a resistance to acknowledging and taking steps to rectify
errors;
•
a lack of cultural
resources for responding constructively to conflict and criticism;
•
an aversion
to being responsible for conveying bad news or for making decisions that may be criticized;
•
the tendency
to make derogatory characterizations of those
with whom one experiences conflict; and
•
a resistance to
acknowledging and grappling sincerely with difficult institu- tional truths,
including the operation of sexism and systemic racism within the RCMP.
LESSON LEARNED
Efforts to reform the police can have
complex results when they are
filtered through the informal norms and values of police organizations.
Management culture is an important
determinant of the success of efforts at police
reform.
RCMP MANAGEMENT CULTURE
The Commission
recommends that
(a)
Within six months of the publication of this Report,
the RCMP commissioner provide
to the responsible minister and the Management Advisory Board, and publish on
the RCMP website, a document that explains the criteria on which the RCMP
presently selects, develops, recognizes, and rewards its commissioned officers
and those in equivalent civilian roles. This document should include a detailed
explanation of the following:
(i)
how the RCMP will
change these criteria to disrupt the unhealthy aspects of the RCMP’s management
culture; and
(ii)
what other steps
are being taken
to address the unhealthy aspects
of the RCMP’s management culture that are identified in this Report, in
the Bastarache Report, and by the Brown Task Force.
(b)
Starting no later
than one year after publication of this Report, the Commissioner should provide
semi-annual written updates to the responsible
minister and the Management Advisory
Board on its progress
in addressing the recommendations made in this Report. These updates should include
timelines for the achievement of each milestone
and should also be posted to
the RCMP website.
Chapter 11 The Future
of Policing in Nova Scotia
LESSON LEARNED Community
safety and well-being must be community- specific. Layers of harms caused by
colonialism and racism mean that a policing response to endemic issues
that arise from those harms
in First Nations,
inuit, and Métis communities
must be developed through a sincere community engagement process that respects indigenous laws and provides
equitable funding for indige-
nous community safety
and well-being.
LESSON LEARNED
in the absence of comprehensive mental
health care services, a significant amount of police
time is spent
providing crisis mental
health responses to Nova
Scotians. Police are not well placed to provide these services. Wherever
possible, mental health crisis response should be reallocated to trained mental
health care providers, and these providers should
be adequately funded
to perform this role.
PROVIDING MENTAL HEALTH CARE TO NOVA SCOTIANS
The Commission
recommends that
(a)
The Province of Nova
Scotia should establish a comprehensive and adequately funded model of mental health
care service provision for urban
and rural Nova Scotians. This model should include first response to those in mental health crisis and continuing community
support services to prevent mental health crises from
arising or recurring.
(b)
The federal
government should subsidize the cost of these services
at a minimum proportion equal to the proportion to which it subsidizes RCMP policing services.
IMPLEMENTATION POINTS
•
We do not make a recommendation about the specific
model of mental health care to be adopted, but
encourage the provincial government
to consult and engage with community stakeholders in choosing
the appropriate model, and to make evidence-based decisions
that are informed by a diverse
representation of community members.
•
Regardless of the model chosen, these decisions should prioritize dignity
and care within a mental health care framework
over a criminal justice response.
(c)
A certified mental health specialist should be embedded
in the 911 public safety answering point locations across
the province and available on call
24/7 to assist with assessing and triaging mental health calls.
IMPLEMENTATION POINTS
•
This specialist may
both ensure community members are connected with the appropriate non-police
allied community safety agency and provide guidance to police responders when
they must respond in person.
•
This resource is
especially important in rural areas where mental health teams may not be an available
resource on the ground in a reasonable response time period.
•
The comprehensive
model should encompass consideration of how 911 standard operating procedures should be updated
to reflect that
mental health service providers are most often the more
appropriate first responders to mental
health calls, but that police
will be dispatched to these calls when the mental
health service provider
indicates that this is
necessary.
LESSON LEARNED Effective police governance is vital to democratic policing. All participants in police
governance, including board members, police leaders, and government officials,
should be properly trained and aware of the role and responsi- bilities of
governing boards.
POLICE GOVERNANCE IN NOVA SCOTIA
The Commission
recommends that
(a)
The provincial
Department of Justice design and provide mandatory standard training in police
governance.
IMPLEMENTATION POINTS
This training
should be mandatory
for:
•
every municipal police chief, H Division RCMP commanding officer,
and detachment commander;
•
provincial and
municipal civil servants whose work includes the administration of police; and
•
police board members and police advisory
board members.
This training
should:
•
address
the governance, oversight, and democratic accountability functions of police boards and police advisory boards;
•
incorporate the eight principles of policing;
•
address findings,
lessons learned, and recommendations set out in this report, the Marshall
Report, the ipperwash Report, the Morden Report, the Thunder Bay Police
Services Report, the Epstein Report, the Wortley Report, and the Public Order Emergency Commission Report; and
•
explain the
respective roles and responsibilities of board members, police leaders, and
civil servants.
(b)
The Nova Scotia Department of Justice should prepare a police board manual and police advisory board
manual.
IMPLEMENTATION POINTS
This manual should:
• be published
on the Nova Scotia Department of Justice website;
•
address
the governance, oversight, and democratic accountability functions of police boards and police advisory boards; and
•
set out the roles and
responsibilities of board members, police leaders, and civil servants.
(c)
Municipalities should provide adequate
funding to police boards to permit
them to conduct independent research, seek legal advice, maintain records, and
otherwise discharge their governance role.
(d)
Municipalities and the Province
of Nova Scotia should ensure that police boards and police advisory boards
are fully staffed and performing their governance function.
IMPLEMENTATION POINTS
•
All seats on police
boards and police advisory boards should be filled through robust recruitment
initiatives for qualified and diverse candidates able to make the necessary
time commitment;
•
municipalities and the province
should ensure that boards are meeting at least every three months, in accordance
with the Police Act; and
•
where a board is not
meeting, or a board member is not attending meetings, that failure must be addressed
in no more than the span of two
meetings.
(e)
The Province of Nova
Scotia should support police boards and police advisory boards to establish an
independent website and public contact information to facilitate direct
communication with the communities they represent and to facilitate sharing
best practices with other police boards.
IMPLEMENTATION POINTS
•
This website should
host board governance policies, procedures, written directions to chief
officers, and records of key decisions taken by the board; and
•
where written directions or records of key decisions
cannot be made public due to operational relevance or for other reasons,
a summary of the
nature of the direction must be posted
as an interim measure, and the
direction or decision itself should be posted if and when the reason for withholding that information lapses.
(f)
Police boards and
police advisory boards should hold their meetings in a place customarily open to the public. Advance
notice of the time, place, agenda, and expected speakers
should be posted
on the board website.
(g)
Police board members
and police advisory board members should be proactive in establishing
relationships with other community safety providers and with members of
communities that have historically been underserved and overpoliced.
(h)
Municipalities and the Province
of Nova Scotia
should ensure that police board members and police advisory
board members are fairly
compensated for their work if they are not serving as part of
another paid role (e.g., as a municipal employee). Lack of compensation is a
barrier to the participation of many community members whose voices should be
represented in police governance.
PUBLISH POLICE POLICIES
The Commission
recommends that
(a)
The Nova Scotia
Minister of Justice should issue a policing standard that requires police
agencies that provide police services in Nova Scotia to publish – online and in
an accessible form and location – policies and standard operating procedures that govern the interaction of police with the public, the manner in which
policing services are provided to the public, and public communications.
(b)
This standard should
require that, where a policy or procedure or a portion of a policy or procedure
is deemed confidential, the police service must
provide a public description of each exempted
section and the reason why it has been deemed confidential.
(c)
The federal minister of public safety should issue a written directive to the commissioner of the RCMP, directing compliance with this provincial standard.
LESSON LEARNED
Specialized policing services are
integral to modern policing. These services should be organized to meet demand
throughout the Province of Nova Scotia on an equitable basis.
SPECIALIZED POLICING SERVICES
The Commission
recommends that
The Province of Nova Scotia should ensure that specialized
policing services are adequate, effective, and efficiently organized to meet
the demand throughout Nova Scotia, whether by contract with RCMP or by other
means:
(a)
Clear and equitable guidelines should be established for how all police
agencies may access these specialized services.
(b)
These guidelines
should also apply to the agency that supplies these services.
(c)
Priority of access
should be determined by prospective guidelines, not by the identity
of the requesting agency or by personal
relationships.
(d)
A police
agency that meets
the criteria for access to these services
should receive them, and arrangements should be put in place to ensure
that disputes between provincial and municipal agencies
about cost allocation do not create a barrier to
access when needed.
INTEGRATED TEAMS
The Commission
recommends that
Police agencies that establish integrated or interoperable teams
with other agencies should settle memorandums of understanding, policies, and
procedures to govern the operation and management of these teams.
LESSON LEARNED
The work performed by public safety
answering point employ- ees is highly gendered, extremely stressful, and
undervalued in our community safety ecosystem.
STRENGTHENING NOVA SCOTIA 911
The Commission
recommends that
The Nova Scotia Emergency Management Office and Public Safety
and Security Division of the Nova Scotia Department of Justice should study how
best to ensure that recruitment, training, compensation, employee supports,
policies, and procedures for public safety answering points are of a quality
and standard that appropriately reflects the important role played by 911 call-takers in our community safety and
well-being ecosystem.
LESSON LEARNED
When conflict among police agencies is
allowed to persist, public confidence is undermined and operational
effectiveness may be impeded.
ADDRESSING
CONFLICT AMONG
POLICE AGENCIES IN NOVA SCOTIA
The Commission
recommends that
(a)
The Province of Nova
Scotia should consult with municipal police leaders and RCMP H Division
leaders to identify
the issues that continue to cause conflict, and to establish a
facilitated process for resolving them. Commitments and resolutions made as a
result of this process should be documented,
and the Province
of Nova Scotia
should hold police
leaders accountable for implementing them.
(b)
The Province of Nova Scotia should make in-person conflict resolution
training mandatory for all current Nova Scotia
chiefs and deputy chiefs and for any candidate who applies to one of these positions.
IMPLEMENTATION POINT
The Province of Nova Scotia should contract with an external
provider that has an established track
record in delivering effective conflict resolution training, to deliver this training.
(c)
The Province of Nova
Scotia should establish a dispute resolution mechanism by which an impartial
and knowledgeable third party can resolve disputes among policing agencies,
or between policing
agencies and the Province of Nova Scotia.
(d)
The Province of Nova
Scotia should establish a policing standard that requires policing agencies to
call on one another to provide backup or assistance when appropriate, and that requires
those agencies called
upon to provide that assistance to the extent of their ability to do so.
LESSON LEARNED Transforming
the structure of policing requires the collabo- rative work of community members, community safety
experts, government, and police.
THE FUTURE STRUCTURE OF POLICING
IN NOVA SCOTIA
The Commission
recommends that
The Province of Nova Scotia should within six months of
publication of this Report establish a multisectoral council comprising representatives of
municipal police agencies and RCMP, community safety experts,
and diverse community representatives to engage with community members and
experts and review the structure of policing in Nova Scotia. This council
should make recommendations that can be implemented before the 2032 expiration of the
Provincial Police Services Agreement.
Chapter 12 Police
Discretion
LESSON LEARNED Perpetrators of violence do not necessarily remain within a single police jurisdiction. Effective
information sharing among police agencies is essential to ensure that patterns
in perpetrator behaviour can be recognized.
INFORMATION SHARING
The Commission
recommends that
(a)
Police agencies
in Nova Scotia
work with the Nova Scotia
Department of Justice to establish shared standards for the collection,
retention, and sharing of information by police agencies.
(b)
Police agencies
in Nova Scotia
work with the Nova Scotia
Department of Justice to
establish policies and procedures for raising concerns when a member of one police agency believes
that a member of another
police agency may not have acted on information that flags a significant risk to
community or police safety.
Chapter 13 Five Strategies for Improving Everyday Policing
LESSONS LEARNED Research-based approaches for best practices
in police recruitment exist and have been successfully implemented in other jurisdictions.
Recruitment strategies designed to increase the
number of police officers from under-represented backgrounds will fail if they are not accompanied by educa-
tional and cultural change in Canadian policing.
RECRUITMENT
The Commission
recommends that
(a)
Canadian police
education programs should
adopt research-based
approaches to student admission processes, based on a clear understanding of
the personal characteristics that form the basis for effective democratic
policing.
(b)
Canadian police agencies
should adopt research-based approaches to police recruitment, based on a clear understanding of the personal characteristics that form the
basis for effective democratic policing.
(c)
Canadian police
agencies should establish a comprehensive strategy for recruiting and retaining
employees who are presently underrepresented in Canadian policing.
IMPLEMENTATION POINTS
•
This strategy should
include measures that are designed to support such recruits and allow them to work to the strengths for which they are
recruited.
•
Police agencies
should change established practices and procedures where necessary to establish a safe and welcoming workplace for recruits from
historically under-represented backgrounds.
LESSON LEARNED
The existing Canadian standard of police
training outside Quebec is inadequate to equip police
for the important work they do and for the
increasingly complex social,
legal, and technological environment in which
they work. The shortcomings produced by this approach have a
disproportionate adverse impact on those who have historically been underserved by police. A three- year
police education program in which a research-based curriculum both precedes and
undergirds practical training is necessary to equip front-line police officers
to exercise legitimate discretion.
CANADIAN POLICE EDUCATION
The Commission
recommends that
(a)
All Canadian
governments and police agencies should,
by 2032, adopt a
three-year police education degree as the minimum standard
for police education.
(b)
Police education programs should employ subject matter experts
who use research-based approaches to design and deliver curriculum, particularly
in areas where police services currently underperform.
(c)
Police education
programs should offer financial support to indigenous and racialized students
and other students from backgrounds or identities that have historically been under-represented in Canadian police services.
Financial means should not be a barrier to obtaining a police education.
MAIN FINDING RCMP
policy and everyday practices with respect to member note-taking practices and supervision of member notes are deficient. The national
note-taking policy is not adhered to, including with respect to custody of the
notebooks, and there is no consistent supervisory practice of monitoring the quality and
content of member notes. Further, there is no daily practice of securing the notebooks
at detachments.
For this reason, courts, tribunals, and the public need to be
aware that simply because something is not reflected in a police officer’s
notes does not mean it did not
happen. Police notes can serve only as a record of what police officers choose
to include and how well they capture the information. The notes should not be
understood as comprehensive. Courts, tribunals, and the public should exercise caution
in drawing inferences from an absence
of RCMP members’
notes or omissions in notes taken.
LESSONS LEARNED
Member notebooks are the primary record
of police officers’ daily activities and decision-making.
Note taking is a crucial
means by which
low-visibility decision-making can be
supervised and democratic policing principles can be secured. Proper
supervision of this basic
aspect of policing
– note taking – is also an important internal accountability mechanism. Such supervision includes
file review and follow up where
gaps are identified in note taking and investigation. This supervision is
not for punitive reasons; it is to facilitate learning by
front-line officers and to ensure
that front-line members are addressing the needs of the communities they serve.
Regular review also ensures that supervisors gain insights into a member’s
judgment and can identify areas and act on areas for improvement.
NOTE TAKING
The Commission
recommends that
(a)
The RCMP, following
the recommendation made by the Civilian Review and Complaints Commission,
should implement training and supervisory strategies to ensure that all members
take complete, accurate, and comprehensive notes.
(b)
The RCMP should
develop an effective asset management process to retain, identify, store, and
retrieve the completed notebooks of its members.
(c)
Canadian police
agencies should evaluate front-line supervisors’ oversight of front-line members’ note taking
as one criterion by which
their performance is assessed.
(d)
Canadian police
education programs should
integrate effective note- taking practices into every
aspect of their
curriculum – for example,
by incorporating note-taking skills and assessment into substantive assignments.
IMPLEMENTATION POINTS
•
All Canadian
police agencies should adopt the practice of requiring front- line members to provide
their notebooks to their supervisor at the end of
each shift for review and countersigning.
•
Where necessary,
electronic alternatives to these supervisory practices (e.g., scanning
notebook pages for review and approval by a remotely located supervisor) can be
adopted.
•
The quality of an
agency’s note-taking practices should be assessed both by compliance with notebook review
policies and by the quality
of members’ note taking.
•
Police notebooks should be stored in police detachments between shifts.
•
When members are transferred, resign, or retire, their notebooks should remain
at their detachment.
•
Canadian police
agencies should explore
the potential for transitioning to electronic note taking in light of available technologies such as cellphone voice recognition note-taking
ability and the increased use of body-worn cameras. Regardless of the platform,
the fundamentals of good note taking should be present, including the essential
requirement of being able to ensure the integrity of records taken
contemporaneously with the events they recount.
MAIN FINDING
The RCMP does not have an effective system of front-line super-
vision in place for general duty members in H Division. This gap deprives
general duty members of day-to-day feedback about their performance, including
how they exercise discretion.
LESSON LEARNED Front-line supervision and the provision
of regular feedback to front-line members are essential components of effective everyday
policing
practices in order to promote a culture of good judgment,
accountability, and taking institutional responsibility for member learning.
SUPERVISION
The Commission
recommends that
(a)
The RCMP should review
the structure of contract policing
services delivered in H Division to ensure that every general duty member receives
routine and effective supervision, including regular feedback on the
quality of low-visibility decision-making.
(b)
Shift meetings
should become a standard practice
at the beginning of every general duty shift in RCMP contract
policing. Supervisors should receive training
in how to run an effective shift
meeting.
IMPLEMENTATION POINT
if the structures we have identified as problematic in H Division
also exist in other RCMP
divisions, this recommendation should be followed in those divisions too.
LESSONS LEARNED Police
decision-making is better when police recognize and draw on the expertise
of community leaders
and other community
safety providers to help them
understand their work.
in order to rebuild police legitimacy, police must interact with
every community member in a way that indicates they fundamentally respect
the people they are
serving and behave in ways that will be constructive for relationships between
police and community members.
COMMUNITY- ENGAGED POLICING
The Commission
recommends that
(a)
Police agencies
should adopt policies
and practices that encourage front- line police to consult with
community subject matter experts on questions that will help them better understand and serve their communities. These policies
and practices should permit consultation on operational matters.
(b)
Community subject
matter experts should be paid fairly for their work, and police agencies
should establish a budget for this purpose.
Chapter 14 Everyday
Policing, Equality, and Safety
LESSON LEARNED
Naming and countering the operation of
misogyny, racism, homophobia, and other inegalitarian attitudes within policing
must be placed at the heart of strategies to improve everyday
policing. if police
continue to disbelieve
women, operate in ignorance about how violence
and trauma present, and work in a silo rather than as part of a coordinated community
safety system, the problems we have documented in this Report will
persist.
COUNTERING SYSTEMIC BIAS
The Commission
recommends that
Government, police agencies, and police education programs make the goal
of identifying and countering the operation of misogyny, racism,
homophobia, and other inegalitarian attitudes central to every strategy
for improving the quality of everyday policing in Canada.
LESSONS LEARNED
Not every complaint received by police
can or should result in charges
being laid or a warrant
being obtained. However,
in every case in which a
community member reports
violence or a non-frivolous fear of violence
to police,
the police should consider it their primary
responsibility to work with other agencies
to prevent escalation of violent
behaviours, to investigate, and to protect
the safety of those who are
at risk.
Recruiting and educating police with an eye to building a
culture of respect for equality
rights and commitment to countering gender-based violence is an essential part
of community-engaged policing.
Documenting patterns of violence through
good note taking
and supervision, information sharing,
and interoperability is critical to assist police and other gender-based violence advocacy and support sector
members to identify
and act upon red flags in
communities.
PREVENTING VIOLENCE AND PROTECTING SAFETY
The Commission
recommends that
Government, police agencies, and police education programs
emphasize that working with other gender-based violence advocacy and support sector members to prevent an escalation of violence and protect the safety of those
who experience violence is the primary purpose
of every police response to a
complaint of violence or the expressed fear of violence.
Chapter 3 Keystone:
Fostering Collaboration
and Ensuring Accountability
LESSONS LEARNED No one person or organization has the authority or formal responsibility to implement all of the recommendations made in this Final Report.
Recommendations in some public inquiry reports are not fully
implemented because of obstacles to reform and the lack of clear
lines of accountability.
implementation of the recommendations in Turning the Tide Together is a respon- sibility shared among many
agencies within the Canadian and Nova Scotian public safety systems and a large
group of other actors and agencies, including community groups and members of
the public.
Shared responsibility is effective only when it is led by
champions; advocated for by stakeholders, communities, and individuals; and supported through mecha-
nisms for monitoring and accountability.
Mutual accountability, clear public
reporting, and ongoing public engagement are key
to overcoming obstacles and supporting institutional change, cultural shifts,
and substantive change over the short, medium, and long term.
TURNING
THE TIDE TOGETHER IMPLEMENTATION
AND MUTUAL ACCOUNTABILITY BODY
The Commission
recommends that
(a)
By May 31, 2023, the
Governments of Canada and Nova Scotia should establish and fund an implementation and Mutual Accountability Body with a mandate to
(i)
provide mutual
accountability, exchange of knowledge, and support
among all organizations and actors involved in the implementation process;
(ii)
consult with
community members on priority areas for action and on implementation strategies;
(iii)
establish a
monitoring framework and monitor on an ongoing basis, including through the
power to request information from federal, Nova Scotian, and municipal public
authorities;
(iv)
take active steps to encourage members
of the public to participate in the whole of society
engagement recommended in this Report;
(v)
provide public
information about the process of implementing the recommendations;
(vi)
provide public
updates on progress on the implementation plan every three months and publish
an annual report on the status of implementation of each recommendation; and
(vii) liaise with implementation efforts in other provinces and territories.
(b)
By May 31, 2023, the
Governments of Canada and Nova Scotia should appoint the Founding Chair and
Champion of the implementation and Mutual Accountability Body following
consultation with all Commission Participants and representatives of the communities most affected by the
April 2020 mass casualty, including the Mi’kmaw communities most affected
and representatives of African Nova Scotian communities.
![]()
(c)
By July 31, 2023, the
Founding Chair, in consultation with representatives of organizations with responsibility mandated by this Report’s
recommendations and other interested individuals and organizations, should
present the Governments of Canada and Nova Scotia with a proposed list of members
and budget for the implementation and Mutual
Accountability Body.
(d)
By September 1, 2023,
the Governments of Canada and Nova Scotia should jointly appoint the membership
of the implementation and Mutual Accountability Body.
(e)
As soon as
practicable, the implementation and Mutual Accountability Body should develop a
plan for monitoring implementation and establish reporting and accountability
mechanisms; it should provide the plan to Parliament and the Nova Scotia
Legislature, and take other steps to make it available to members of the
public, including through the establishment of a dedicated website that tracks
updates and progress.
(f)
The implementation
and Mutual Accountability Body should provide public updates on progress on the
implementation plan every three months and publish an annual report on the
status of implementation of each recommendation
IMPLEMENTATION POINTS
Composition: The implementation and Mutual Accountability Body
should include the following members:
•
at least two
representatives of those most affected by the mass casualty (including families
of the deceased and/or survivors);
•
a civic representative from one of the affected
municipalities;
•
a representative of RCMP National
Headquarters senior management with authority to act on behalf
of the Commissioner;
•
the
RCMP Deputy Commissioner of Contract and indigenous Policing
•
the
Assistant Commissioner of RCMP H Division;
• a representative of the RCMP Management Advisory
Board;
• a senior representative of Public Safety Canada;
•
a senior representative of Nova Scotia Department of Justice
Public Safety;
•
at least one community-based representative from the gender-based
violence advocacy and support sector;
•
at least one
representative of indigenous community organizations engaged in policing
reform;
•
at least
one representative of African Canadian
community organizations engaged in policing reform;
and
•
on their
establishment, delegates from the other bodies established under the Report’s
recommendations:
◇ the Federal and Nova Scotia Community Safety and Well-Being
Leadership Councils (Recommendation C.17 );
◇ the Gender-Based violence Commissioner (Recommendation v.17) or
their appointee.
Advisory Group: The implementation and Mutual Accountability Body should consider establishing an advisory group consisting
of other agencies engaged in the Canadian and Nova Scotian public safety
systems, policing organizations, the health sector, and victims’ advocacy organizations.
Facilitating implementation: The implementation and Mutual
Accountability Body should
•
circulate the
Commission report and recommendations to stakeholder communities, and communicate and consult with community members
on priority areas for action and on implementation strategies; and
•
provide the report to the Auditor
General of Canada
and the Auditor General of Nova Scotia so they
might inquire into the progress of implementing these recommendations.
Status reports: Updates
should include analysis
of information to identify
trends, obstacles, delays,
problems, issues, and best practices.
Rationale for Non-implementation: To encourage transparency,
where an organization has decided not to implement a recommendation or part of
a recommendation, the implementation and Mutual Accountability Body will
request a written explanation of this decision and publish it in reports under
the implementation plan.
Chapter 5 Recommendations Related to Future Public
Inquiries
PRE- INQUIRY PHASE
The Commission
recommends that
There should be a consultation phase prior to the establishment of an inquiry. During this phase, governments should identify the commissioner(s) and, pursuant to an appropriate
confidentiality undertaking, engage them in discussion about the draft terms of
reference in order to ensure the mandate is realistic.* in particular, the scope of the mandate
must be achievable in the time frame allotted.
* There is precedent for such discussions. For example, in the Arar inquiry, Commissioner Dennis O’Connor
with his counsel
Paul Cavalluzzo negotiated the mandate (see Bessner and Lightstone, Public Inquiries in Canada: Law and Practice
(Toronto: Thomson Reuters,
2017), 28–29 and 77–78).
PREPARATORY PHASE
The Commission
recommends that
Following this brief
pre-inquiry phase, the Orders in Council should
provide for a three-month preparatory phase to allow the commissioners time to
(a)
establish appropriate infrastructure such as office space, computers, and phones,
(b)
develop a website, and
(c) hire start-up support staff.
Only then should
the mandate clock
start ticking toward
the due date of the final report.
EXTERNAL INDEPENDENT AUDIT
The Commission
recommends that
An external independent audit of the RCMP and the Attorney
General of Canada’s document management and
production processes be conducted, with the results made public.
DESIGNATED DOCUMENT DISCLOSURE BODY
The Commission
recommends that
The federal government create a designated body to assist the Attorney General of Canada with document
disclosure generally.
FORM OF DOCUMENT
PRODUCTION
The Commission
recommends that
Public inquiries should be authorized to direct the manner in
which participants must produce documents in their possession.
PART F: NEXT STEPS
Community safety
is a shared responsibility and a shared opportunity. We all need to be
champions for change, taking the recommendations from this Report and
implementing them in our communities, workplaces, organizations, and policies.
Some recommendations can be
implemented relatively quickly and easily, while others will take more time and
collaboration, both within and between different groups and institutions. in
order to build and sustain momentum over the months and years required to make
the longer-term changes, people from many different settings and roles across
society will need to keep taking action, being
advocates, and holding each other accountable in ways that are supportive and
constructive.
Many of the recommendations we make will require action
by leaders and teams in government and public institutions
such as the RCMP. in the Final Report, we make
a number of recommendations to strengthen existing accountability
mechanisms or to create new ones. Most important, we are calling
for the federal and Nova Scotia governments to jointly
form an implementation and Mutual Accountabil-
ity Body that will include representatives from government, the RCMP, those
most affected, and key community
groups. This body will be responsible for creating
an implementation plan and providing regular updates to government and to the public.
The Commission was established to serve the public interest. We worked in a trans- parent fashion and took steps to engage a wide range of people and organizations.
As our successor, the implementation and Mutual Accountability Body should pick
up and expand this mantle. We have recommended that this body be established on an urgent basis: its framework,
funding, and founding chair in place by May 31, 2023,
and the appointment of the members, after consultation with interested indi- viduals and organizations, by September 1, 2023. The implementation and Mutual
Accountability Body should
become active that month and issue its first report
to the public before the year 2023 ends.
We urge readers to
learn more about our recommendation for the Implementa- tion and Mutual
Accountability Body in Volume 6, Implementation.
for the Broader Community
The Final Report provides
a range of recommendations for how to reach our shared goal of making our communities safer. We have made many recommen-
dations that will need to be taken up by political leaders, policy-makers, and
the RCMP, along with other public institutions and service providers. As discussed, it is critical that these recommendations are taken seriously
and with the required
degrees of urgency by the relevant leaders and institutions.
At the end of volume 6, implementation, we look beyond
public leaders and insti-
tutions, focusing instead
on the next steps and actions that individuals and groups
in our communities can take to make the places
we live safer
for everyone. These actions may also be relevant to political leaders, first responders, and other institu-
tional representatives acting in their capacity as family members,
neighbours, and community members.
We know that the scale of the task
ahead can seem overwhelming, and it can be difficult to know where to begin,
let alone how to remain engaged and to sustain momentum. We set out here some
reflections on the potential strengths and capa- bilities that different
individuals and groups could tap into, based on what we have
observed during the course
of our work and what we have learned from other
instances of mass violence and harm.
Many people have asked us what they can do. While we have made suggestions for different groups of people,
we know there are areas of overlap
and that many groups and individuals may have started
this work and will have other applicable and effective suggestions. The
suggestions include some of the core things we can all do every day that will help to make our communities stronger,
such as reach- ing out to build relationships with each other, checking
in and listening to each other regularly, and supporting each other to speak up and seek help whenever it is needed.
|
Group |
Potential Actions |
|
Those most affected |
•
Stay in contact with
each other, providing mutual support based
on your shared experiences. •
Continue to find ways
to commemorate those
whose lives were
taken, both to honour their memories and so others can learn about
what happened and be inspired to act. •
Continue to urge
your elected representatives at the municipal, provincial, and
federal levels to take action based
on the recommendations in this Report. You could write
letters and request meetings to talk about actions,
accountability, and progress. •
Form an ongoing
advocacy group to coordinate and organize your efforts. Similar groups have been
formed by people
affected by other mass casualties. For example,
family members of the children whose lives were taken during the Sandy Hook
Elementary School shooting in 2012 went on to
create Sandy Hook Promise. This national non-profit organization promotes gun violence prevention education to youth and adults
in the United States. • Join a local
community organization or board, sharing your unique
experience and perspective. •
Continue to seek help if you or someone
you know needs it. Reach out
to your family, friends, or a dedicated support organization in your community. |
|
Group |
Potential Actions |
|
Community organizations and advocacy groups |
•
Talk about how the
findings and recommendations included in this Report are relevant to your community and discuss ways to incorporate them into your ongoing
activities. •
inform your
community about the factors that can lead to mass casualties, including
gender-based, intimate partner, and family violence, and help to create a culture in which it is fine
for people who are experiencing violence to speak up and get
help. •
Build on the networks and coalitions that
have been established or strengthened between your group and other organizations.
This collaborative approach will
make everyone stronger. •
Continue to urge
your elected representatives and public institutions to pay attention and to take action. •
Use this Report,
along with the commissioned reports (available in Annex B) and other
materials, as a resource to inform your discussions and work.
These documents include
input from many
people, including those who
experienced the mass casualty and its related issues and experts who specialize in mass violence, gun control, policing, community resilience, and
other relevant issues. |
|
Policy specialists
and researchers |
•
Use this Report,
the commissioned reports (available in Annex B), and the many other materials
created during the inquiry as a resource for ongoing discussion, research, and
policy development. We heard and learned from many experts, and we encourage you to continue to draw on
this wealth of information in your work too. •
Consider designing research projects that
will help to track the
progress that is being made to implement the recommendations in this
Report and to address the underlying issues that contribute to mass
casualties. This work could contribute to a broadening of accountability,
ensuring sustained and shared responses toward building safer communities. •
Continue to foster
and build networks with your policy and research peers, both here in Canada
and around the world. This inquiry benefited
from the input
of many academic collaborators, and we believe future collaboration will play an important
role in building our shared understanding of common challenges and the
progress being made to overcome them. |
|
Members of the public |
•
Be good
neighbours, reaching out
to the people
in your community and supporting them to find help if they need it. •
Be champions for change in your families, communities, and workplaces, speaking up about the
issues that contribute to mass casualties and steps we can take to improve
community safety. •
volunteer in your community, joining a group
or board that
is focused on making your
community stronger. •
Continue to urge
your elected representatives and public institutions to pay attention and to take action. •
Seek help if you or
someone you know needs it. Reach out to your family, friends, or a dedicated support organization in your
community. |
|
Group |
Potential Actions |
|
Media |
Continue to hold public
leaders and institutions accountable, reporting
on their responses to the recommendations in this Report and their
implementation plans, progress, and outcomes. Help inform the
public about the
broad and systemic issues detailed in this
Report that contribute to mass casualties, including gender-based and
intimate partner violence. Contribute
to building a culture where
everyone feels safe
to speak up and
seek help if they need it. |
|
Businesses |
Make sure everyone working
in your organization feels supported to speak
up if they need any kind of help, including if they are experiencing gender- based, intimate partner, or
family violence. This support could form part of your organization’s safety and diversity, equity, and
inclusion (DEi) commitments and programs. Direct some of your corporate giving and
employee volunteering efforts toward community organizations and non-profits that focus on community
safety. Host
forums that encourage discussion about the role that businesses play in contributing to safer communities
for everyone. Such events could be in collaboration with other businesses,
community organizations, or with a chamber of commerce in your community. |
|
Educators |
Ensure that your school or classroom
is a respectful and inclusive environment where students feel supported to
speak up. Talk with your students about the mass
casualty, the Commission, and this Report,
encouraging discussion about the recommendations and collective responses
to terrible events and shared challenges. Help your students learn about gender,
healthy masculinities, and power, encouraging them to think about ways of
being that are inclusive and safe for all. Talk
about the importance of bystander intervention. Lead and provide opportunities for
research projects in colleges and universities to address the gaps identified in volume 3, violence. |
|
Children and
youth |
Talk with
your parents, families, friends, and teachers about your ideas
to make your community safer. Seek help from
someone you trust or a dedicated support organization if you or someone you
know is experiencing any kind of violence or mental health issue,
or just generally needs help. |
No one can undo the perpetrator’s actions or the actions taken by others in
response: these actions are the epicentre of concentric circles of impact
caused by the April 2020 mass casualty,
along with its precursors and aftermath. The rip-
ple effect of the mass casualty cannot be erased. Steps can be taken, however,
to arrest its path from extending ever outward and becoming more
all-encompassing. Collectively, individuals, communities, Nova Scotia, and Canada can learn from this
incident and work together toward enhanced safety and well-being in the future.
An appreciation of the depth and breadth of this ripple effect is an essential
com- ponent of effective, concerted, forward-looking efforts. The
recommendations of this Commission
can create a sea change that will absorb these ripples over time and usher in
opportunities – marking a shift toward the future. it is time to turn the tide together.
in this Report, we added a second image and dimension
to our framework to
complement the ripple image and mark a shift toward the future: turning the
tide together. This tide metaphor also signifies the transition from the Commission to those charged with implementation: governmental institutions and agencies, community-based organizations, communities, and individuals both in their pro-
fessional roles and as citizens.
Our work ends with the completion of this Report, but more difficult work lies
ahead. Although some reforms have been undertaken since the mass casualty, many
of the lessons to be learned from the systemic fail- ures have yet to be considered – and, critically, acted upon. Given this circum- stance, some of the
recommendations in this Report require profound changes to institutions and to
the ways agencies and communities work together to create an effective public safety system.
The recommendations also encompass measures to encourage cultural shifts –
measures that necessitate changes at the individual, relationship, community,
and societal levels. in short, our recommendations call for a whole of society response and
engagement.
“Turning the tide” is an expression used to describe
a significant change
in direc- tion, including
by going against
an existing current
or pattern within society. Turn- ing the tide requires community, political, and institutional leaders to help shape a counter-current as well as the momentum
to establish and support new patterns.
The most powerful currents are
created by many people working together as a community. it is our hope that this Report will harness the outrage and compassion
needed to create a wellspring of commitment to the substantive changes
required to restore trust and enhance community safety and well-being, followed
by the actions needed to implement those changes. Turning
away from the responsibil-
ity to see, feel, and act in response to the mass casualty and its antecedents
is unimaginable. in light
of the traumatic losses and continuing impact
of the mass casualty, facing the tide and turning it in a new direction is the only acceptable
course. it is also our hope that our recommendations, many of which were con-
tributed by Participants and the public, have two key results: they assist in shaping
this momentum to turn the tide on violence; and they strengthen our resolve not
to accept the current reactive responses
to it.
We chose the tide metaphor in part out of recognition of Cobequid Bay, an inlet of the Bay of Fundy. The bay’s name
is derived from the Acadian spelling of the Mi’kmaw word We'kopekwitk, as the area was called. The shores of Cobequid Bay are important to many people living in Colchester, Cumberland, and Hants coun- ties – in Mi’kma’ki. The April 2020 mass casualty
is the most fatal mass shooting
in Canadian history, and it occurred in a series of rural communities beginning on Cobequid Bay’s northern
shore. Now is the time to act collectively to change
the course of the tidal wave of violence that was set into motion many years ago,
that reached a critical point
on April 18 and 19, 2020, and that continues beyond this time and place. Turning
the tide requires
both a reckoning with this past and accepting responsibility to contribute to a safer future.
Everyone has a role to play individually and collectively to achieve this shared,
communal goal. The first step is to stand against
the tide: to resist coming to pre- mature conclusions or relying
on pre-existing judgments
about the mass casualty
and the response to it and, instead, to read this Report with an open mind.
ide- ally, this first act will lead to more engagement: reflecting on the
contents and rec- ommendations and, crucially, talking about it with family, friends, and colleagues.
After that, many paths will open up: with or against the tide, in the central
stream of change, or at its edges. These
are decisions that we each will make and, as a
result, each of us in our own way will be a part of the ultimate response to the mass casualty
and its aftermath.